H18-A3

Vol. 24 No. 38
Replaces H18-A2
Vol. 19 No. 21

Procedures for the Handling and Processing

of Blood Specimens; Approved Guideline—
Third Edition

This document includes criteria for preparing an optimal serum or plasma sample and for
the devices used to process blood specimens.
A guideline for global application developed through the NCCLS consensus process.

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 NCCLS...
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NCCLS is an international, interdisciplinary, nonprofit, Most NCCLS documents are subject to two levels of
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 H18-A3
ISBN 1-56238-555-0
Volume 24 Number 38 ISSN 0273-3099
Procedures for the Handling and Processing of Blood Specimens;
Approved Guideline—Third Edition
Roger R. Calam, Ph.D., DABCC
J. David Bessman, M.D.
Dennis J. Ernst, M.T.(ASCP)
Susan S. Smith
Diane I. Szamosi, M.A., M.T.(ASCP), SH
David J. Warunek, Ph.D., M.B.A.
Joan D. Wiseman, M.T.(ASCP), CT

Abstract
NCCLS document H18-A3—Procedures for the Handling and Processing of Blood Specimens; Approved Guideline—Third
Edition considers multiple variables that are involved in handling and processing blood specimens. Its application should enable
the user to recognize and control accuracy and precision factors that occur between the time of blood collection and the time of
test performance.

Criteria for optimal serum, plasma, or whole blood samples are established, as well as criteria for the performance of in vitro
devices used to process blood specimens. Implementation of recommended procedures should assist laboratories in the pursuit of
excellent performance, with useful, accurate patient test results as the ultimate goal.

NCCLS. Procedures for the Handling and Processing of Blood Specimens; Approved Guideline—Third Edition. NCCLS
document H18-A3 (ISBN 1-56238-555-0). NCCLS, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898 USA,
2004.

THE NCCLS consensus process, which is the mechanism for moving a document through two or more levels of review by the
healthcare community, is an ongoing process. Users should expect revised editions of any given document. Because rapid
changes in technology may affect the procedures, methods, and protocols in a standard or guideline, users should replace
outdated editions with the current editions of NCCLS documents. Current editions are listed in the NCCLS Catalog, which is
distributed to member organizations, and to nonmembers on request. If your organization is not a member and would like to
become one, and to request a copy of the NCCLS Catalog, contact the NCCLS Executive Offices. Telephone: 610.688.0100;
Fax: 610.688.0700; E-Mail: exoffice@nccls.org; Website: www.nccls.org

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 Number 38 NCCLS

This publication is protected by copyright. No part of it may be reproduced, stored in a retrieval system,
transmitted, or made available in any form or by any means (electronic, mechanical, photocopying,
recording, or otherwise) without prior written permission from NCCLS, except as stated below.

NCCLS hereby grants permission to reproduce limited portions of this publication for use in laboratory
procedure manuals at a single site, for interlibrary loan, or for use in educational programs provided that
multiple copies of such reproduction shall include the following notice, be distributed without charge,
and, in no event, contain more than 20% of the document’s text.

Reproduced with permission, from NCCLS publication H18-A3—Procedures for the

Handling and Processing of Blood Specimens; Approved Guideline—Third Edition
(ISBN 1-56238-555-0). Copies of the current edition may be obtained from NCCLS, 940
West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898, USA.

Permission to reproduce or otherwise use the text of this document to an extent that exceeds the
exemptions granted here or under the Copyright Law must be obtained from NCCLS by written request.
To request such permission, address inquiries to the Executive Vice President, NCCLS, 940 West Valley
Road, Suite 1400, Wayne, Pennsylvania 19087-1898, USA.

Copyright ©2004. The National Committee for Clinical Laboratory Standards.

Suggested Citation

(NCCLS. Procedures for the Handling and Processing of Blood Specimens; Approved Guideline—Third
Edition. NCCLS document H18-A3 [ISBN 1-56238-555-0]. NCCLS, 940 West Valley Road, Suite 1400,
Wayne, Pennsylvania 19087-1898 USA, 2004.)

Proposed Standard Approved Guideline—Third Edition

October 1981 November 2004

Tentative Standard
March 1983

Approved Guideline
December 1990

Approved Guideline—Second Edition

October 1999

ISBN 1-56238-555-0
ISSN 0273-3099

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 Volume 24 H18-A3

Committee Membership

Area Committee on Hematology

Bruce H. Davis, M.D. Maryalice Stetler-Stevenson, M.D., Ph.D. Richard A. Marlar, Ph.D.
Chairholder National Institutes of Health Oklahoma City VA Medical Center
Maine Medical Center Research Bethesda, Maryland Oklahoma City, Oklahoma
Institute
Scarborough, Maine Advisors Diane I. Szamosi, M.A., M.T.(ASCP)SH
Greiner Bio-One,
Samuel J. Machin, MB, Ch.B, Charles F. Arkin, M.D. VACUETTE North America, Inc.
FRCPath Lahey Clinic Monroe, North Carolina
Vice-Chairholder Burlington, Massachusetts
The University College London Luc Van Hove, M.D., Ph.D.
Hospitals J. David Bessman, M.D. Abbott Laboratories
London, United Kingdom University of Texas Medical Branch Abbott Park, Illinois
Galveston, Texas
Dorothy M. Adcock, M.D. Staff
Esoterix Coagulation Sheila Clover, CPT(ASCP)(NCA)
Aurora, Colorado Phlebotomy West David E. Sterry, M.T.(ASCP)
Brentwood, California Staff Liaison
Frank M. LaDuca, Ph.D. NCCLS
International Technidyne Corporation Dennis J. Ernst, M.T.(ASCP) Wayne, Pennsylvania
Edison, New Jersey Center for Phlebotomy Education
Ramsey, Indiana Donna M. Wilhelm
Ginette Y. Michaud, M.D. Editor
FDA Center for Devices and John A. Koepke, M.D. NCCLS
Radiological Health Durham, North Carolina Wayne, Pennsylvania
Rockville, Maryland
Francis Lacombe, M.D., Ph.D. Melissa A. Lewis
Albert Rabinovitch, M.D., Ph.D. Laboratoire d’Hematologie Assistant Editor
Abbott Laboratories Pessac, France NCCLS
Hematology Business Unit Wayne, Pennsylvania
Santa Clara, California Kandice Kottke-Marchant, M.D., Ph.D.
The Cleveland Clinic Foundation
Cleveland, Ohio

Acknowledgement

NCCLS gratefully acknowledges the experts and institutions listed below for their help in preparing the
approved-level third edition of this guideline.

Roger R. Calam, Ph.D., DABCC St. John Hospital

J. David Bessman, M.D. University of Texas Medical Branch
Dennis J. Ernst, M.T.(ASCP) Center for Phlebotomy Education
Susan S. Smith Sarstedt, Inc.
Diane I. Szamosi, M.A., M.T.(ASCP), SH Greiner Bio-One, VACUETTE North America, Inc.
David J. Warunek, Ph.D., M.B.A. BD VACUTAINER Systems
Joan D. Wiseman, M.T.(ASCP), CT Consultant

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 Number 38 NCCLS

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 Volume 24 H18-A3

Contents

Abstract ....................................................................................................................................................i

Committee Membership........................................................................................................................ iii

Foreword .............................................................................................................................................. vii

1 Scope..........................................................................................................................................1

2 Introduction................................................................................................................................1

3 Standard Precautions..................................................................................................................1

4 Definitions .................................................................................................................................1

5 Description of the Product Class................................................................................................2

6 Whole Blood Processed to a Serum or Plasma Sample .............................................................2

6.1 Precentrifugation Phase ................................................................................................4
6.2 Centrifugation Phase...................................................................................................10
6.3 Postcentrifugation Phase.............................................................................................13
7 Serum and Plasma Separator Devices......................................................................................14
7.1 Devices Used During Centrifugation..........................................................................14
7.2 Devices Used After Centrifugation.............................................................................17
7.3 Tube Closure...............................................................................................................17
7.4 Device Shelf-Life........................................................................................................17
7.5 Interferences................................................................................................................17
References.............................................................................................................................................19

Summary of Comments and Area Committee Responses ....................................................................23

Summary of Delegate Comments and Area Committee Responses .....................................................25

The Quality System Approach..............................................................................................................32

Related NCCLS Publications................................................................................................................33

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 Volume 24 H18-A3

Foreword
This guideline specifies criteria that should assist the laboratory and other healthcare providers in
recognizing and reducing or eliminating preanalytic error resulting from improper handling of blood
specimens. The document is the result of considerable discussion and comment; appropriate references
are indicated.

Recognition of the need for procedures that address the different areas of specimen collection is
evidenced by the following NCCLS documents:

• H1—Tubes and Additives for Venous Blood Specimen Collection;

• H3—Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture;

• H4—Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens;

• H11—Procedures for the Collection of Arterial Blood Specimens;

• H18—Procedures for the Handling and Processing of Blood Specimens; and

• H21—Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based

Coagulation Assays.

In this document, certain abbreviations have been used: AST (aspartate aminotransferase, SGOT); ALT
(alanine aminotransferase, SGPT); LD (lactic dehydrogenase, LDH); CK (creatine kinase, CPK); APTT
(activated partial thromboplastin time); T3 (tri-iodothyronine); T4 (thyroxine); and PCV (packed cell
volume).

This document replaces the second-edition approved guideline, H18-A2, which was published in 1999. A
number of changes have been made in this edition; chief among them is the expansion of the
recentrifugation section to include gel and non-gel tubes (see Section 6.2.3). The recommendation that gel
tubes should not be used for the collection of ionized calcium specimens has been deleted from Section
7.5 for consistency with NCCLS document C31—Ionized Calcium Determinations: Precollection
Variables, Specimen Choice, Collection, and Handling.

Key Words

Chilled specimens; criteria for specimen rejection; handling and processing specimens; precentrifugation,
centrifugation, and postcentrifugation phases; serum or plasma contact with clot or cells; serum/plasma
separator devices; tube closure

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 Volume 24 H18-A3

Procedures for the Handling and Processing of Blood Specimens;

Approved Guideline—Third Edition

1 Scope
This guideline addresses handling and processing of blood specimens for analytical determinations using
serum, plasma, or whole blood in the clinical laboratory. The variables associated with precentrifugation,
centrifugation, and postcentrifugation phases of specimen handling and processing are emphasized.
Where applicable, the recommendations should be considered by the following laboratory areas:
chemistry, coagulation, hematology, immunology, ligand assay, serology, toxicology/therapeutic drug
monitoring, virology, blood bank, and molecular or DNA analysis.

2 Introduction
This guideline addresses the multiple factors associated with handling and processing blood specimens.
These factors can introduce test result inaccuracy or systematic bias after the specimen has been collected
but before the test is performed. Performance criteria for in vitro diagnostic blood collection devices used
to separate serum or plasma from cellular components are also addressed.

Several issues in the handling and processing of blood specimens are documented in the scientific
literature.1-12 Specific concerns relate to prolonged contact of serum or plasma with cells or with tube
stoppers; hemolysis; analyte concentration changes due to evaporation; incorrect storage temperature; the
use of anticoagulants and serum/plasma separator devices; incorrect transport; and turnaround time (TAT)
for patient results. Recognition and control of these variables should reduce error and contribute to the
medical usefulness of patient test results.

3 Standard Precautions

Because it is often impossible to know what might be infectious, all patient and laboratory specimens are
treated as infectious and handled according to “standard precautions.” Standard precautions are guidelines
that combine the major features of “universal precautions and body substance isolation” practices.
Standard precautions cover the transmission of all infectious agents and thus are more comprehensive
than universal precautions which are intended to apply only to transmission of blood-borne pathogens.
Standard and universal precaution guidelines are available from the U.S. Centers for Disease Control and
Prevention (Guideline for Isolation Precautions in Hospitals. Infection Control and Hospital
Epidemiology. CDC. 1996;17(1):53-80 and MMWR 1988;37:377-388). For specific precautions for
preventing the laboratory transmission of all infectious agents from laboratory instruments and materials
and for recommendations for the management of exposure to all infectious disease, refer to the most
current edition of NCCLS document M29—Protection of Laboratory Workers from Occupationally
Acquired Infections.

4 Definitions
Accuracy (of measurement) – Closeness of the agreement between the result of a measurement and a
true value of the measurand (VIM93).13

Analyte – Component represented in the name of a measurable quantity (ISO 17511)14; NOTES: a) In
the type of quantity “mass of protein in 24-hour urine,” “protein” is the analyte. In “amount of substance
of glucose in plasma,” “glucose” is the analyte. In both cases, the long phrase represents the Measurand

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(ISO 17511)14; b) In the type of quantity “catalytic concentration of lactate dehydrogenase isoenzyme 1 in
plasma,” “lactate dehydrogenase isoenzyme 1” is the analyte (ISO 18153).15

Centrifugation phase – The time period when the specimen is inside the centrifuge.

Error (of measurement)//Measurement error – The result of a measurement minus a true value (or
accepted reference value) of the measurand (VIM93)13; NOTES: a) Since a true value cannot be
determined, in practice a conventional true value is used (VIM93); b) When it is necessary to distinguish
“error” from “relative error,” the former is sometimes called absolute error of measurement. This
should not be confused with absolute value of error, which is the modulus of the error (VIM93); c)
Formerly, the term “total error” was often used in NCCLS documents.

Postcentrifugation phase – The time period after the centrifuging of the specimen and before removal of
an aliquot of serum or plasma for testing.

Precentrifugation phase – Time period after specimen collection and before specimen centrifugation.

Sample – One or more parts taken from a system, and intended to provide information on the system,
often to serve as a basis for decision on the system or its production.

Secondary tube – A tube used to contain the resultant plasma/serum yielded by the centrifugation of a
primary additive/serum tube containing the patient specimen.

Separated serum/plasma – Serum or plasma that has been completely separated from any contact with
cells or a clot; NOTES: a) The serum or plasma has either been removed, by pipette, from the cells or
contact has been interrupted by a chemical/physical barrier through the use of a serum/plasma separator
device (see Section 7); b) The separated serum/plasma should be visually free of erythrocytes; however,
0.1% to 1% intact cells do not contribute to a hemolysis effect.7

Specimen (patient) – The discrete portion of a body fluid or tissue taken for examination, study, or
analysis of one or more quantities or characteristics to determine the character of the whole.

5 Description of the Product Class

This guideline provides recommended criteria for correct handling of whole blood specimens and serum
or plasma samples. Specifications for the optimal performance of in vitro diagnostic devices used in the
processing of blood specimens are also provided. Devices in this class include integrated blood collection
serum or plasma separator devices; devices inserted into the collected blood specimen before initiating
centrifugation; and devices used to harvest the serum or plasma after centrifugation.

6 Whole Blood Processed to a Serum or Plasma Sample

Recommendation: Serum or plasma should be physically separated from contact with cells as soon as
possible, unless conclusive evidence indicates that longer contact times do not contribute to result error. A
maximum limit of TWO HOURS from the time of collection is recommended.

NOTE: A contact time of less than two hours is recommended for potassium,16 ACTH, cortisol,8
catecholamines,17 lactic acid,18 and homocysteine.19

For some specimens, temperature affects stability.4,20,21 However, many analytes have not been studied.

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 Volume 24 H18-A3

The following studies support a two-hour precentrifugation time limit as recommended in this document:

The Laessig, et al study5 determined that the 17 analytes below were unaffected by a precentrifugation
serum-cells contact time as long as 48 hours (room temperature):

• albumin;
• alkaline phosphatase;
• ALT;
• bilirubin;
• calcium;
• cholesterol;
• CK;
• creatinine;
• magnesium;
• phosphorus;
• sodium;
• total protein;
• triglycerides;
• T3;
• T4;
• urea nitrogen; and
• uric acid.

However, altered results were clinically significant for the following:

By two hours:

• glucose (decreased);
• potassium (increased); and
• LD (increased).

By eight hours:

• iron (increased).

AST showed a slight increase, and chloride a slight decrease, with time. Whereas this study did not
indicate any change for magnesium, other investigators report a magnesium increase by four hours at
4 oC.22

In the Chu and MacLeod study of 26 analytes,23 the effects of a 72-hour contact time at room temperature
were determined. Many of the aforementioned 48-hour stable analytes retained stability for an additional
24 hours. In addition, amylase, bicarbonate, cortisol, and gamma-GT were also stable. Analytes adversely
affected by 72-hour contact include: glucose (decreased); potassium (increased); phosphorus (increased);
creatinine (increased); folate (decreased); and vitamin B12 (increased). Minimally affected analytes
include: LD (increased); chloride (decreased); calcium (decreased); ferritin (increased); and sodium
(increased). A 72-hour study by Ruby, et al24 confirmed ALT stability at 4 o C and 22 oC.

In addition to the analytes in the previous references, a multianalyte study by Rehak and Chiang4
determined stabilities of lipase, TBG, and TSH in unseparated serum for 24 hours at seven different
temperatures (3 oC, 10 oC, 15 oC, 22 oC, 25 oC, 30 oC, and 38 oC). Generally, 22 to 25 oC is considered
room temperature, and at 22 oC, changes were observed for glucose (decreased); potassium (increased);
phosphorus (increased); ALT (increased); AST (increased); and creatinine (increased). The higher the
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temperature, the more accentuated the alteration. Another time-temperature study (at 0 oC, 23 oC, and 30
o
C) by Ono, et al20 substantiates the instability of many analytes at temperatures above room temperature
(30 oC): glucose (decreased by four hours); phosphorus (increased by six hours); ALT and AST
(increased by eight hours); and potassium (increased by 24 hours). As expected,25,26 potassium was
significantly increased at temperatures below 15 oC.

In a few studies of selected analytes, ionized calcium in unseparated serum was stable for only two hours
at 25 oC, but stable for up to 96 hours at 4 oC.27,28 Ionized magnesium was stable at room temperature for
over six hours and five days at 4 oC.29 With serum in contact with cells, tricyclic antidepressant drugs are
reported to be stable for six days at 4 oC.30

In a more recent study, Zhang and fellow investigators evaluated the stabilities of 63 analytes, serum in
contact with cells for 24 hours. They determined that serum should be separated from the clot within three
hours for glucose, potassium, and phosphorus, and within six hours for albumin, bicarbonate, chloride, C-
peptide, HDL-cholesterol, iron, LDL-cholesterol, and total protein. All other analytes in their study were
stable for 24 hours without serum separated from the clot. As the authors point out, new laboratory
paradigms require greater knowledge of analyte stability. There are increased transportation/time issues
from specimen collection site to testing laboratory. It is important to decrease false rejections of
acceptable specimens.31

For recommended timing on coagulation testing, please refer to the most current edition of NCCLS
document H21—Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based
Coagulation Assays.

6.1 Precentrifugation Phase

6.1.1 Recommendations

Regardless of the device used for specimen collection, all tubes containing additives except sodium citrate
should be gently inverted at least five to ten times to mix the contents, unless otherwise specified by the
manufacturer. Tubes containing sodium citrate should be inverted three to four times to mix the contents.
(Please refer to the most current edition of NCCLS document H21—Collection, Transport, and
Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays for more detailed
information regarding the precentrifugation phase for coagulation testing.)

6.1.1.1 Serum

Specimens should be clotted before centrifugation. Rimming the tube with a wooden applicator stick to
release the clot is not recommended (see Section 6.1.4.1).

Spontaneous and complete clotting normally occurs within 30 to 60 minutes at room temperature (22 to
25 oC).32 The time to clot will be prolonged if the patient is on anticoagulant therapy. Chilling the
specimen (2 to 8 oC) delays clotting. If the time allowed for the specimen to clot is inadequate, latent
fibrin formation can cause a problem for many instrument systems leading to erroneous results.

To accelerate clotting, a collection device can be used that contains an activator/accelerator (e.g., snake
venom/thrombin, approximately two to five minutes; thrombin, approximately five minutes; and glass or
silica particles, 15 to 30 minutes).6,33-36

6.1.1.2 Plasma

A collection device containing an anticoagulant is used when plasma is required. Anticoagulated

specimens can be centrifuged immediately after collection.

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 Volume 24 H18-A3

6.1.1.3 Chilled Specimens (2 to 8 oC)

Chilling a specimen inhibits the metabolism of blood cells and stabilizes certain thermolabile
constituents. Whole blood specimens are not to be chilled unless there are documented recommendations
for so doing. Chilling whole blood beyond two hours is contraindicated for a specimen intended for
potassium, because cold inhibits glycolysis, which provides energy for pumping potassium into the
cell.20,25 Without this energy, potassium will leak from the cells, falsely elevating the results. Specimens
collected for electrolytes must not be stored at 2 to 8 oC before centrifugation and testing.

To chill a specimen, place it immediately in either crushed ice or a mixture of ice and water. Good contact
between the cooling medium and the specimen is essential. Large cubes of ice instead of water are not
acceptable because of inadequate contact between the coolant and the specimen. The coolant must cover
the specimen level in the device.

The following are examples of tests that require a chilled specimen: catecholamines, ammonia, lactic
acid, pyruvate, gastrin, and parathyroid hormone (PTH).37 Please refer to the most current edition of
NCCLS document H11—Procedures for the Collection of Arterial Blood Specimens for
recommendations regarding specimen collection and handling for pH/blood gas analyses.

6.1.1.4 Metabolic Inhibitors and Preservatives

Collection devices containing an additive (e.g., fluorides) can prevent concentration changes within the
specimen over extended periods of time. The antiglycolytic agent, sodium fluoride, is used to stabilize
glucose in the presence of blood cells for up to 24 hours at 22 to 25 oC or 48 hours at 2 to 8 oC.37

Great care must be taken with newborn and pediatric specimens collected for a glucose determination. It
is difficult to inhibit the glycolytic metabolism of these blood cells.38 This effect is compounded by a
high hematocrit or leukocytosis.39,40 Microcollection devices containing a suitable antiglycolytic agent
may be used for pediatric blood glucose collection.

6.1.2 Transportation

For more information, please refer to the most current government regulations and NCCLS document
M29—Protection of Laboratory Workers from Occupationally Acquired Infections.

6.1.2.1 Blood Specimens Collected On-Site

6.1.2.1.1 Time

Specimens must be transported in the appropriate biohazard bags or containers to the laboratory in as
short a time as possible. Unless chilling of the samples is required, all samples should be transported at
room temperature. Prompt removal of specimens from the collection area is especially important if the
area temperature is above 22 oC, which may cause some analytes to deteriorate.

6.1.2.1.2 Tube Orientation

Where possible, tubes of blood should be kept in a vertical, closure-up position. This positioning
promotes complete clot formation and reduces agitation of the tube contents, which in turn reduces the
potential for hemolysis.

In the past, tube closures in contact with blood have been a source of contamination in
toxicology/therapeutic drug monitoring testing.41-44 The contaminant, tris-butoxyethyl phosphate (TBEP),
interferes in TDM assays by displacing basic drugs from their protein binding sites, resulting in a
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redistribution of drug into the erythrocytes with a decreased amount of drug left in the serum or plasma
for assay. TBEP has been eliminated by tube manufacturers and is no longer a problem.

Special tubes are now available for trace element studies (e.g., zinc, copper, and selenium). They have
minimal closure/tube contamination.45-47 These tubes are recommended.

6.1.2.1.3 Specimen Agitation and Hemolysis

Gentle handling of collected specimens helps to minimize erythrocyte damage. Hemolyzed specimens
may cause chemical interferences and interference with some optical instrumentation. Young, et al48 have
listed the chemical constituents whose concentration in serum and plasma may be affected by hemolysis.
It has been reported that plasma containing 20 mg/dL (200 mg/L; 0.012 mmol/L) of hemoglobin is faintly
pink, and plasma containing 100 mg/dL (1 g/L; 0.06 mmol/L) of hemoglobin is red.49 Other studies,
however, have reported that as much as 190 mg/dL (1.9 g/L; 0.12 mmol/L) of hemoglobin may not
always be visually evident.50 Elevated bilirubin in the plasma may mask hemoglobin, and a hemoglobin
concentration of 200 mg/dL (2 g/L; 0.124 mmol/L) may not be detected by the unaided eye if the
plasma contains 20 mg/dL (200 mg/L; 342 µmol/L) of bilirubin;51 detection of discoloration also
depends on the diameter of the tube being viewed.

Tests7 seriously affected (all increased) include:

• LD;
• AST;
• potassium; and
• plasma hemoglobin.

Tests noticeably affected include:

• iron (increased);
• ALT (increased); and
• T4 (decreased).

Tests slightly affected (all increased) include:

• phosphorus;
• total protein;
• albumin;
• magnesium;
• calcium; and
• acid phosphatase.

Technological advances have made possible the assay of several analytes in whole blood (sodium,
potassium, chloride, glucose, BUN, creatinine, ionized calcium, etc.). If hemolysis is present, it is
masked when the sample is whole blood, and it may be responsible for an erroneous result. It is
recommended that laboratories using whole blood instruments check for hemolysis when results are
beyond specific designated concentrations (e.g., potassium >5.5 mmol/L) to determine if the result is
erroneous because of the hemolysis. The specimen, or an aliquot of the specimen, should be centrifuged
and the plasma visually inspected.

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6.1.2.1.4 Exposure to Light

It is important to avoid exposing blood specimens for photosensitive analytes to artificial light or sunlight
(ultraviolet) for any length of time. For bilirubin, this is critically important when an icteric newborn is
being monitored for the possibility of an exchange transfusion.52 Further examples include vitamins A and
B6, beta-carotene, and porphyrins. These specimens should be protected with an aluminum foil wrap, an
amber specimen container, or the equivalent.

6.1.2.2 Off-Site

6.1.2.2.1 Remote Collection Sites

The stability of the specimen dictates conditions for transport from remote collection sites (e.g.,
physicians’ offices, satellite draw stations) to the testing location. If an uncentrifuged whole blood
specimen is to be sent to the laboratory for testing, it must reach the laboratory in time to be processed
with serum/plasma separation occurring in a time limit to protect the stability of the analytes. If this
requirement cannot be met, the specimen must be centrifuged at the collection site, with the serum or
plasma separated from the cells and held under appropriate conditions (see Section 6.3) until it can be
delivered to the laboratory. Secondary tubes must be leak-proof. Specific handling and processing
requirements published by the testing laboratory should also be consulted.

6.1.2.2.2 Courier Services

A courier service used to transport specimens or samples from a physician’s office, remote blood-drawing
station, or another laboratory, should pay particular attention to adequate packaging and handling to
ensure constituent stability for the tests requested. (See the most current government regulations and
NCCLS document M29—Protection of Laboratory Workers from Occupationally Acquired Infections for
specific details.) Of critical importance is attention to transport conditions that are either too hot (summer
transportation) or too cold (winter transportation).8

6.1.2.3 Automated Delivery Systems

Pneumatic tubes are the predominant automated transport system for specimen delivery to the laboratory.
The effects of these systems on the validity of laboratory results have been evaluated.53-60 The results vary
according to the particular tube system, but in general, the tests affected are those influenced by the
disruption of red cell membrane integrity. The tests most often cited are LD, potassium, plasma
hemoglobin, and acid phosphatase.

Other testing areas that are not appropriate for pneumatic tube delivery systems are samples that must be
maintained at body temperature, including cryoglobulins and cold agglutinins.

Reports indicate that transport does not affect the following tests in any of the tube delivery systems:

• albumin;
• alkaline phosphatase;
• AST;
• chloride;
• creatinine;
• glucose;
• sodium;
• total bilirubin;
• total protein;

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• urea nitrogen;
• uric acid;
• leukocyte count; and
• thrombin time.

Unless specific documentation already exists, automated transport systems, pneumatic or otherwise,
should be evaluated for any effects on laboratory results.

6.1.3 Receipt of Unprocessed Specimens by the Laboratory

6.1.3.1 Time

Upon receipt, specimens should be sorted and prepared for centrifugation. Allow sufficient time for
clotting to occur. Blood collected using a tube containing a clotting activator (e.g., thrombin, silica, or
glass particles) can be processed as early as 5 to 30 minutes after the blood is drawn. Anticoagulated
specimens can be centrifuged immediately (see Sections 6.1.1.1 for serum and 6.1.1.2 for plasma). Also
refer to manufacturers’ specific recommendations.

Some tests require an unseparated, anticoagulated whole blood specimen (e.g., blood lead, cyclosporin,61
and glycohemoglobin/A1C). These specimens are not to be centrifuged. If accidentally centrifuged, do not
discard the specimen; send the centrifuged tube to the testing location.

6.1.3.2 Temperature

Chilled specimens (2 to 8 oC) are to be kept at this temperature until they are ready to be centrifuged.
Temperature-controlled centrifuges are recommended (see Section 6.2.2).

6.1.3.3 Tube Orientation

It is recommended that tubes of blood be placed in a vertical, closure-up position upon delivery to the
laboratory.

6.1.3.4 Tube Closure

Tubes of blood are to be kept closed at all times. Certain test results can be inaccurate when the tube
closure is removed because of an increase in specimen pH resulting from the loss of carbon dioxide (e.g.,
pH [increased], ionized calcium [decreased], and acid phosphatase [decreased]). Keeping the tube in a
closed position eliminates possible exogenous contamination of the specimen and prevents evaporation
and the possibility of spills and aerosols.

6.1.3.5 Criteria for Specimen Rejection

Under the following conditions, blood specimens may not be acceptable for testing purposes. Professional
judgment at the laboratory director/supervisor level must be exercised in applying these criteria:

• Inadequate Specimen Identification

Example: A tube of blood is not labeled or it is inadequately labeled.

The most current edition of NCCLS document H3—Procedures for the Collection of Diagnostic Blood
Specimens by Venipuncture should be consulted for recommended labeling requirements. In addition,
consult facility policy.

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• Inappropriate Volume of Blood

The amount of additive placed into a tube is intended for a certain volume of blood. If less blood than
required is drawn, the excess amount of additive has the potential to adversely affect the accuracy of test
results.57,62-64 If more blood is drawn than is required, the amount of additive may be insufficient for its
intended purpose and may similarly adversely affect the accuracy of test results.65 Specific references
should be consulted to help avoid short-draw or over-draw additive problems.

Example 1: Sodium citrate: prothrombin time.66

Example 2: EDTA: PCV, cell count, cell morphology, lipids.67-70

Example 3: Heparin: CK, aminoglycosides (gentamicin, tobramycin).71,72

• Using the Wrong Collection Tube

Method-specific specimen requirements must be considered. In particular, tubes with additives are not to
be used indiscriminately. An additive can interfere with the analyte to be determined.48

Example 1: Sodium fluoride interferes in the urease urea nitrogen method.73

Example 2: The wrong order of draw during multiple blood specimen collection can invalidate results
because of contamination by the additive.9

• Hemolysis

Hemolysis can occur in vivo or ex vivo. In vivo hemolysis may also be the result of a disease process
causing intravascular erythrocyte destruction. Repeated blood collection and continued receipt of
hemolyzed specimens often indicates intravascular hemolysis and the physician should be notified.
Hemolysis can result from a difficult venipuncture or from improper handling of the collected specimen.
Hemolysis can occur when blood is drawn from a catheter with connectors having very small or large
internal diameters. The changes in the internal diameters may cause turbulence and result in cell
disruption with hemolysis. Certain tests will be inaccurate when the specimen is hemolyzed in vitro7 (see
Section 6.1.2.1.3).

• Improper Storage/Transportation

Example 1: A specimen that should have been chilled (2 to 8 oC) is received by the laboratory unchilled.

Example 2: A serum or plasma sample that should have been frozen is received thawed by a reference
laboratory.

6.1.4 Preparing Specimens for Centrifugation

6.1.4.1 Clot Release (Rimming the Tube)

The use of a wooden applicator stick or similar device for the release of a clot attached to the tube closure
or the sides of the tube is not recommended. Rimming the tube is a potential source for
laboratory-induced hemolysis.74 Clot/cell hang-up has been virtually eliminated by technical
improvements in tube/closure design and manufacture. If rimming should be necessary, great care should
be exercised in removing the closure and in reclosing the tube to prevent aerosol formation. Many
laboratories remove tube closures behind a plastic shield or within a biological safety cabinet. It is
important to reclose the tube or use a suitable closure and make sure the closure stays in place.
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6.1.4.2 Tube Closure

Tubes of blood are to be kept closed at all times. If a separator device must be inserted into the tube
before centrifugation (see Section 7.1.3), and the device does not cover the tube opening, a closure must
be used.

6.2 Centrifugation Phase

Blood specimens for serum samples should be adequately clotted before centrifugation. Tubes should be
centrifuged with their closures in place and with a centrifuge that has an adequate closure.

Tubes of blood intended for whole blood analysis are not to be centrifuged and separated (see Section
6.1.3.1).

6.2.1 Centrifuge Time and Relative Centrifugal Force (rcf)

6.2.1.1 Recommendations

The manufacturer’s literature, which makes recommendations for specific blood collection devices,
should be consulted. Advancements in technology may provide for adequate specimen preparation at
different speeds and times of centrifugation.

6.2.1.2 Relative Centrifugal Force (rcf)

Relative centrifugal force (g-force) is a more meaningful term than revolutions per minute (rpm). This
document recommends that laboratories describe centrifuge requirements in terms of rcf. The rpm is of
limited use to the reader without an indication of the centrifuge model and its specific rotor and head, and
the effective radius. The effective radius is the distance measured from the rotor axis to the bottom of the
fluid inside the tube at the greatest horizontal distance from the rotor axis.

(a) Calculating rcf

rcf = 1.118 x 10-5 x r x n2

where:

r = rotating radius (cm); and

n = speed of rotation (rpm).

(b) Relative Centrifugal Force Nomograph (see Figure 1)

6.2.2 Temperature-Controlled Centrifuges

6.2.2.1 Recommendations

Laboratories should have temperature-controlled centrifuges for temperature-sensitive analytes.

Centrifuges can generate internal heat that may be inappropriate for analyte stability (e.g., coagulation
studies). Specific thermolabile analytes should be separated at 4 oC (e.g., ACTH, cyclic-AMP). Check to
make sure the centrifuge is at its intended setting. Unless documentation supports a specific temperature
for a specific analyte, a centrifuge setting of 20 to 22 oC is recommended.2

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6.2.2.2 Chilled Specimens

Specimens that are transported to the laboratory chilled should be centrifuged under temper-
ature-controlled conditions. For a specimen requiring chilled centrifugation, and potassium is one of the
requested tests, prompt removal of the specimen from the centrifuge is required (see Section 6.1.1.3).
Temperatures lower than 15 °C can falsely elevate potassium results after two hours.4,25

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ROTATING TIP RADIUS

The distance measured from the rotor axis to the tip of the liquid inside the tubes at the greatest horizontal
distance from the rotor axis is the rotating tip radius. The radius is listed for your convenience in the
speed and force tables.

Figure 1. Relative Centrifugal Force Nomograph. Because models and sizes of centrifuges vary
considerably, the use of gravity (g) forces instead of revolutions per minute (rpm) is suggested. A
nomograph for calculating centrifugal speed is provided. The rotating radius of the centrifuge head is the
basis for the calculation and it must be carefully determined. Information on this procedure is also
provided. Reprinted with permission from Thermo Electron Corporation, Milford, MA 01757, U.S.A.
Tel: (866) 9THERMO; Fax: (508) 634-2199; Email: info.sampleprep@thermo.com.

6.2.3 Recentrifugation

Specimens for potassium measurement should not be centrifuged more than once. Results will be falsely
increased.75-78

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NOTE: A literature search was performed for the years 1966 to 2004. Four references specifically
indicate that specimens for potassium should not be recentrifuged.75-78 No other analytes were cited.
However, the area committee cautions that the potential for inaccuracy for other analytes is possible.
Laboratories may wish to conduct studies when there are unexplained results possibly attributable to
recentrifugation, for example, when the time between centrifugation and recentrifugation has been
lengthy, as can occur between offsite blood collection locations and the testing laboratory.

Harvesting of additional serum/plasma AFTER serum/plasma has been removed from non-gel or gel
tubes SHOULD NOT be attempted. When serum/plasma has been removed and harvesting of additional
serum/plasma is attempted, the volume ratio of plasma to erythrocytes has been altered. Analytes from
cellular leakage/exchange, accentuated by clot retraction, will then be centrifuged into the serum/plasma
used for testing. This can cause erroneous results.

6.3 Postcentrifugation Phase

6.3.1 Recommendations

6.3.1.1 Serum/Plasma Contact with Cells/Clot

It is recommended that serum or plasma be physically separated from contact with cells as soon as
possible with a maximum time limit of two hours from the time of collection, unless conclusive
evidence indicates that longer contact times do not contribute to error of the results. Shorter contact times
may be necessary (see Section 6).

6.3.1.2 Storage

6.3.1.2.1 Separated Serum or Plasma

The growing number of laboratory tests mandates that specific references be consulted to determine exact
handling and storage conditions necessary to ensure the stability of specific analytes. It is the
responsibility of the individual laboratory to use all available references and/or their own studies to
determine specific stability criteria for their laboratory.

In 1965, Winsten3 recommended that serum and plasma be refrigerated if testing was not complete within
five hours after collection. There are now several studies indicating that many analytes are stable at room
temperature for 24 to 72 hours, when tubes are stoppered and serum is in contact with cells.4,5,20,23,24 It
seems apparent that an analyte that is stable at room temperature in unseparated serum/plasma should
also be stable at the same temperature for the same length of time in separated serum/plasma. There are
also several stability studies of separated serum. At 2 to 8 oC and room temperature, significant stability
of separated serum has been observed for 2 to 14 days.79-85 However, room temperature (20 to 25 °C) in
the laboratory is a critical stability parameter with decreased stability observed at temperatures above 22
°C for some analytes.4 Based on the studies cited, this guideline makes the following ‘general’
recommendations, recognizing that there can be several exceptions:

• Separated serum/plasma should remain at room temperature for no longer than eight hours. If assays
will not be completed within eight hours, serum/plasma should be refrigerated (2 to 8 oC).

• If assays are not completed within 48 hours, or the separated serum/plasma is to be stored beyond 48
hours, serum/plasma should be frozen at or below -20 oC.

CAUTION: Serum/plasma samples are not to be repeatedly frozen and thawed, since this can cause
analyte deterioration. They are to be thawed only once. Frost-free freezers are not suitable for

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storage, as freeze/thaw cycles allow the temperature of the sample to increase and then drop, allowing the
sample to refreeze.

• Documented references for analytes that do not fall under these generalized rules are to be followed
closely (e.g., insulin, gastrin,79 ionized calcium,27,28 catecholamines,15 and ionized magnesium).29

• If these recommendations conflict with instances in which a serum/plasma separator device is used,
the directions of the manufacturer are to be followed.

6.3.1.2.2 Serum/Plasma Separator Devices

The manufacturer’s directions are to be consulted when a serum or plasma separating device is being
used, either as an integral part of the blood collection tube (gel tubes) or inserted into the tube before or
after centrifugation. These devices are described in Section 7.

After centrifugation, serum or plasma can be left in contact with the gel barrier for a limited time. Consult
the manufacturer’s recommendations for specific limitations. Specific references for the device in use are
to be consulted. For non-gel devices, the time the serum/plasma can be left in contact with the device is
variable. Consult the manufacturer’s recommendations for specific limitations.

6.3.1.2.3 Preservatives

Antiglycolytic agents (e.g., fluorides) may stabilize plasma glucose for 24 hours at 25 oC and for up to 48
hours at 2 to 8 oC when plasma is in contact with cells.37 Inadequate inhibition occurs when erythrocyte,
platelet, or leukocyte counts are abnormally high. Newborn glycolysis is difficult to inhibit. The plasma
from these specimens should be separated as soon as possible after collection (see Section 6.1.1.4).

6.3.1.3 Tube Closure

Serum, plasma, and whole blood specimens are kept covered (air tight) at all times to prevent possible
exogenous contamination, evaporation, concentration changes, or possible spillage and aerosols.

7 Serum and Plasma Separator Devices

The description and functional properties of various devices used to separate serum/plasma from whole
blood are covered in this section. Regardless of the type of device, it is important to read the
manufacturer’s instructions and follow their recommendations carefully. If necessary, request additional
performance documentation. Several scientific publications can also be reviewed.86-99

Basically, serum/plasma separator devices are divided into two major categories: those that function
during centrifugation and those that are used after centrifugation.

7.1 Devices Used During Centrifugation

7.1.1 Integrated Gel Tube Systems

7.1.1.1 Descriptions

• Serum

Integrated gel tube systems incorporate a relatively inert gel material into the blood collection tube. These

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gels have a controlled viscosity and a specific gravity intermediate to serum and clot. In addition, a
clotting activator (e.g., glass or silica particles) is contained within the tube. The tube walls and tube
closure are treated to eliminate cell or clot hang-up at the top of the tube. Integrated tube systems do not
require removal of the closure until an aliquot of serum is removed for testing or storage. These systems
are available in a variety of tube sizes.

• Plasma

Plasma gel tubes are identical to serum gel tubes, except that they contain an anticoagulant (e.g., heparin,
citrate, EDTA) in place of the clotting activator.

7.1.1.2 Function

• Serum

When blood enters the tube, the clot activator begins to activate clotting. Complete and rapid clotting is
enhanced by five to ten gentle inversions of the collected blood. During centrifugation, the gel material
forms an impermeable barrier between the serum and the clot. The specific rcf and time requirement
depend on the device used. Consult the manufacturer’s instructions. Barrier formation is more predictable
with swing-bucket centrifuges.

When using a fixed-angle centrifuge, and if serum is to be stored on the gel, visual inspection of the tube
is necessary to check for completeness of the barrier. Barrier formation is more predictable with swing-
bucket centrifuges. However, the gel should be checked for barrier integrity.

• Plasma

The anticoagulant inhibits clotting. Complete anticoagulation is enhanced by five to ten gentle inversions
of the collected blood. Separator function is identical to serum gel tubes.

7.1.1.3 Storage

In general, serum can be stored on the gel for up to 48 hours at 4 oC.82,83 There have been studies for
plasma storage on the gel.6,94 Performance data should be requested from the manufacturer for the device
of interest. If storage beyond this time is necessary, refer to the manufacturer’s recommendations for
specific limitations.

If serum/plasma is to be stored, the gel should be visually inspected for barrier integrity.

7.1.2 Integrated Gel Microcollection Tubes

Serum/plasma microcollection tubes incorporate an inert gel material and are made of plastic. Rapid
clotting is retarded by the nonwettable plastic surfaces. Microcollection gel tubes for plasma contain
either the anticoagulant lithium heparin or EDTA. Serum/plasma can be separated within 60 to 90
seconds using device-specific rcfs of 2000 to 15 000 x g. Consult the manufacturer’s instructions. These
devices have been reviewed.6 (Also see the most current edition of NCCLS document H4—Procedures
and Devices for the Collection of Diagnostic Capillary Blood Specimens.)

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7.1.3 Devices Inserted Into the Collected Blood

7.1.3.1 Gel Devices

7.1.3.1.1 Description

A separator device can incorporate an inert gel material in a small container that is placed into the
evacuated blood collection tube after removal of the tube closure. The gel has a controlled viscosity and a
specific gravity intermediate to serum and clot. These devices can also be used to separate plasma from
cells when the collected blood is anticoagulated. These devices can be used with a variety of tube sizes.

7.1.3.1.2 Function

During centrifugation, the gel material is released from the container into the blood. As centrifugation
continues, a chemical/physical barrier is formed between the serum and the clot. Centrifugation should
occur at a speed and time recommended by the device manufacturer to ensure release of the gel into the
blood to form a barrier.

Serum can be stored on the gel for up to 48 hours. If serum is to be stored, the gel should be visually
inspected for barrier integrity and a suitable closure should be placed on the tube after the device has been
removed from the tube.

7.1.3.2 Non-Gel Devices

7.1.3.2.1 Description

A variety of non-gel devices have been available over the years. These devices are incorporated into the
tube by the manufacturer, or are placed in the tube after specimen collection, and function during
centrifugation. The device is inserted gently to avoid hemolysis of the erythrocytes. A suitable tube
closure is placed on the tube and kept in place during the centrifugation and postcentrifugation phases
until an aliquot of the specimen is removed for storage or testing.

Non-gel devices have been made from a variety of inert materials. They are manufactured to have a
specific gravity intermediate to serum and clot. They can also be used to separate plasma from cells when
the collected blood is anticoagulated.

Depending on the specific product, these devices can be used with a variety of collection tube sizes.

7.1.3.2.2 Function

During centrifugation, the device moves through the blood to an interface between the serum/plasma and
the clot/cells. An rcf of 1000 to 1100 x g is used for ten minutes unless the manufacturer or a scientific
reference indicates otherwise. An individualized study may be necessary to determine if the rcf
requirement for a specific device influences the accuracy of test results.

These devices are referred to as “barriers” between serum/plasma and clot/cells.91 The word “barrier”
suggests an interruption of contact between the serum/plasma and the clot/cells. If serum/plasma is to be
stored on these barriers, the impermeability of the device to the leakage of analytes (e.g., potassium)
through the barrier to the serum/plasma should be documented by appropriate studies. In the absence of
valid documentation, serum or plasma is removed from contact with the device.

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7.2 Devices Used After Centrifugation

7.2.1 Description

Plunger-type filters are devices used to separate serum/plasma from the clot/cells after the blood tube has
been centrifuged.

The individual device consists of a plastic tube with a filtering unit on the end. The design and
construction of the filtering unit should prevent serum/plasma backflow through the filter and prevent
particulate matter (fibrin) from passing into the filtered serum/plasma. Filters that do not prevent
serum/plasma backflow are not recommended.

Plunger-type filtering devices are available for a wide variety of blood collection tube sizes.

7.2.2 Function

After centrifugation, the plunger-type filter is inserted into the collection tube and gently pushed down
through the serum/plasma to a position above the interface of the serum/plasma and the clot/cells.

It is necessary to keep the filtering unit from touching the clot/cells, because contact is a potential source
of cell hemolysis. A gap is created between the device and the tube contents by slightly withdrawing the
device from the tube. The air gap is needed to prevent analyte leakage into the filtered serum/plasma at
the clot/cell surface. If the air gap cannot be created because the design of the device does not prevent
serum/plasma backflow, the separated serum/plasma is removed from the device. For plunger-type
devices that can be used for serum/plasma storage, appropriate documentation is used to validate analyte
stability and the absence of interference when the serum/plasma is left in contact with the specific device.

7.3 Tube Closure

For any separating device that requires the removal of the tube closure for either insertion of the device
before centrifugation or for removal of separated serum or plasma, extreme caution must be exercised to
prevent liquid or aerosol contamination of the work area.

The closure is reseated, or a suitable closure is used both before and after centrifuging the specimen.

7.4 Device Shelf-Life

For all serum/plasma separator devices, adhere to the manufacturer’s stated storage conditions and
expiration dates to ensure proper performance of the device.

7.5 Interferences

Gel device-associated errors have been reviewed.6

• LD: Although statistically significant, differences seen for LD (increased) using gel devices are
considered clinically insignificant.

• Gel devices should not be used to collect blood for progesterone, tricyclic antidepressant drugs, or
direct antiglobulin testing. Gel devices should not be used to collect blood for direct antiglobulin
tests, as the gel can cause red cells to stick together simulating agglutination.100

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• Therapeutic drugs: The laboratory must exercise caution when using gel devices to collect blood for
drug classes such as antiepileptic, cardiac, aminoglycoside, etc. Studies have been contradictory and
device-specific.

Regardless of device type, gel or non-gel, the scientific literature and the manufacturer’s documentation
should be consulted before selecting a device to use.

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References
1
Martinek S. Specimens for clinical laboratory analysis: collection and preservation. Post Grad Med. 1966;37:A46-A56.
2
Calam RR. Blood collection. In: Faulkner WR, Meites S, eds. Selected Methods for the Small Clinical Chemistry Laboratory.
AACC:1982;9:1-10.
3
Winsten S. Collection and preservation of specimens. In: Meites S, ed. Standard Methods of Clinical Chemistry. New York: Academic
Press; 1965;5:1-17.
4
Rehak NN, Chiang BT. Storage of whole blood: effect of temperature on the measured concentration of analytes in serum. Clin Chem.
1988;34:2111-2114.
5
Laessig RH, Indrikson AA, Hassemer DJ, Paskey TA, Schwartz TH. Changes in serum chemical values as a result of prolonged contact
with the clot. Am J Clin Path. 1976;66:598-604.
6
Calam RR. Specimen processing separator gels: an update. J Clin Immunoassay. 1988;11:86-90.
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 Volume 24 H18-A3

NCCLS consensus procedures include an appeals process that is described in detail in Section 8 of
the Administrative Procedures. For further information, contact the Executive Offices or visit our
website at www.nccls.org.

Summary of Comments and Area Committee Responses

H18-A2: Procedures for the Handling and Processing of Blood Specimens; Approved Guideline—
Second Edition

General

1. Recommendations on the accuracy of hematology results on EDTA tubes spun in error, remixed, and run would be helpful.

• Documented studies were not found in the literature. Resuspension of spun EDTA tubes could occur if: 1) plasma
has not been removed from the tube for other testing; and 2) a smear must be made to determine if any platelet
clumping or clot formation or mechanical damage to blood cells has occurred. If platelet clumps or clotting are
present, or there is microscopic evidence of cellular damage, the specimen is unacceptable.

Section 6, Whole Blood Processed to a Serum or Plasma Sample

2. A chart would be helpful in the temperature descriptions.

• The area committee believes that the current presentation of material on temperature and stability is appropriate
due to the wide range of information provided. The user of the guideline may want to extract the information
appropriate for the user’s laboratory and prepare a chart.

3. A contact time of less than two hours is recommended for potassium, ACTH, cortisol, catecholamines, and lactic acid. What
about glucose?

• References indicate that a decrease in glucose occurs by two to three hours after collection. This section does indicate
that altered (decreased) results were clinically significant for glucose at two hours after collection.

Section 6.1.2.1.4, Exposure to Light

4. Suggest mentioning the importance of protecting specimens drawn from patients with liver disease as well. Perhaps it should
be stressed that blood drawn from any patient for liver function tests should be protected from light during transportation
and processing.

• The area committee believes that the subject of light exposure has been appropriately addressed.

Section 6.2.2, Temperature-Controlled Centrifuges

5. The use of a temperature-controlled centrifuge is recommended in this section; however, no recommendations are provided
if a temperature-controlled centrifuge is not available.

• The area committee recommends that laboratories routinely receiving chilled specimens purchase a temperature-
controlled centrifuge. If chilled specimens are infrequent and a temperature-controlled centrifuge is not available,
then handle these specimens as expeditiously as possible. For example, select a centrifuge that has not been operating
recently and therefore is at room temperature. Centrifuge for the minimum time recommended. Immediately remove
the specimen when the centrifuge comes to a stop. Chill the spun specimen until testing can be completed.

Section 7.1.1.1, Descriptions

6. This paragraph (serum) seems to be based on the assumption that all gel separator serum tubes contain a clot activator. In
fact, glass serum tubes without a clot activator are still widely used.

• This paragraph for serum refers only to integrated gel tube systems that always contain a clot activator. Tubes
without gels are not included in Section 7.1.1.1.

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 Number 38 NCCLS

Section 7.1.1.2, Function

7. This paragraph seems to be based on the assumption that all gel separator serum tubes contain a clot activator. In fact, glass
serum tubes without a clot activator are still widely used.

• See response to Comment 6.

Section 7.1.3.1, Gel Devices

8. The rcf we normally use is 3500g for ten minutes. Do we need to spin at that speed since there is a minimum of 500g for
tubes with gel? Does it matter?

• The area committee believes the reviewer means 3500 r.p.m. for ten minutes. Regardless, the area committee
recommends following the manufacturer’s directions for the device in question.

Section 7.1.3.2.1, Description

9. Given the risk involved in manually inserting such devices, and the prevalence of much safer serum separator options,
consider revising to discourage using devices that require the user to open tubes rather than to recognize them as a valid
alternative. Even though Section 7.3 urges caution when using such devices, discouraging the use of such devices outright
seems more appropriate.

• Integrated collection devices are certainly safer to use; however, if a laboratory chooses to use nonintegrated devices,
particular attention to safety issues must be exercised.

Section 7.5, Interferences

10. This section states, “…gel devices should not be used to collect blood for ionized calcium or progesterone.” Does this
include tubes that have an integrated gel tube system or only for devices (gel or otherwise) inserted into the tube after
collection? We collect both of these tests into a gel tube.

• This section has been revised to remove the recommendation that ionized calcium cannot be collected in gel tubes.
Please refer to NCCLS document C31-A2—Ionized Calcium Determinations: Precollection Variables, Specimen
Choice, Collection, and Handling; Approved Guideline—Second Edition, which states, “The difference between plain
and “gel separator” serum tubes for ionized calcium and pH is clinically insignificant if manufacturer’s instructions
for use of tubes are followed; either may be used for ionized calcium measurements.”

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 Volume 24 H18-A3

Summary of Delegate Comments and Area Committee Responses

H18-A3: Procedures for the Handling and Processing of Blood Specimens; Approved Guideline―
Third Edition

General

1. No reference to changes in RBC and platelet indices with time from venous sampling for CBC.

• Young’s Preanalytical text cites studies that show RBCs to be stable for at least one week at room temperature and at
refrigerated temperatures and that platelets are stable for at least 24 hours refrigerated (studies on room
temperature stability are contradictory). No studies are mentioned of platelet indices (MPV). Further information
may be available from the specific instrument manufacturer. Reference: Young D. Effects of Preanalytical Variables
on Clinical Laboratory Tests. AACC Press. Washington, DC; 1997.

Section 1, Scope

2. Laboratory specialty areas NOT mentioned are chemistry, blood banking, and newborn screening.

• The text has been revised as follows:

“…the recommendations should be considered by the following laboratory areas: chemistry,…virology, blood
bank…”

Section 5, Description of the Product Class

3. Suggest wording change. “This guideline provides recommended criteria for the collection of optimal whole blood
specimens and serum/plasma samples. Specifications for optimal performance of in vitro diagnostic devices used in the
processing of blood specimens is also provided...”

• The text has been revised as follows:

“This guideline provides recommended criteria for correct handling of whole blood specimens and serum or plasma
samples. Specifications for the optimal performance of in vitro diagnostic devices used in the processing of blood
specimens are also provided.”

Section 6, Whole Blood Processed to a Serum or Plasma Sample

4. Discussion covers most of chemistry issues but lacks in immunology information specifically in reference to storage
temperatures of -20 °C are not addressed which is a recommendation for immunology tests.

• The many immunology tests that are routinely performed make researching the stability of each antibody and
antigen almost impossible and it is beyond the scope of this document to assess the stability of every analyte. Please
refer to the manufacturer’s product insert for specific storage recommendations. In addition, Section 6.3.1.2.1 states:
“If assays are not completed within 48 hours, or the separated serum/plasma is to be stored beyond 48 hours,
serum/plasma should be frozen at or below -20 ˚C.” Immunology specimens can also be stored at -80 ˚C for long-
term storage as needed for multicenter clinical trials.

5. Should state what is needed up front:

“Serum or plasma should be physically separated from contact with cells as soon as possible unless conclusive evidence that
longer contact times do not contribute to result inaccuracy.”

Delete “for some specimens” and replace with:

“Note: A contact time of less than…

For some specimens, temperature affects stability. However, many analytes have not been studied.”

Reference(s) is written but only one is cited.

“The following reference supports a two-hour precentrifugation time limit as recommended in this document:
The Laessig, et al study5 determined that 17 analytes were unaffected by precentrifugation serum-cell contact time as long as
48 hours (room temperature)…”

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 Number 38 NCCLS

• The area committee believes Section 6 is accurate as written. The two-hour recommendation is supported by all of
the studies described in Section 6.

The text has been revised as follows: “The following studies support a two-hour precentrifugation time limit as
recommended in this document.”

6. However, altered results were clinically significant for the following.

“By two hours.” What does this mean? Up to and two hours? After two hours? If it is by two hours, shouldn’t the time then
be shortened to prevent spurious results? If it is ‘after,’ you may want to clarify:

After two hours post blood collection:

• Glucose was decreased

• Potassium was increased
• LD was increased

After eight hours post blood collection:

• Iron was increased.

Again if using the word ‘others’ for reference, then cite more references than one. You may want to change wording to
reflect citation:

“…any change for magnesium, another reported a…”

• The recommended time limit of two hours is considered appropriate as the studies used to arrive at the two-hour
time limit do not indicate if changes were occurring just after collection or just prior to or at two hours. A laboratory
may wish to use a time limit of less than two hours.

The text has been revised as follows to clarify “others”: “AST showed a slight increase, and chloride a slight
decrease, with time. Whereas this study did not indicate any change for magnesium, other investigators report a
magnesium increase by four hours at 4 ˚C.”

7. States LD is increased at two hours and is “clinically significant,” yet nine lines down states that LD is “minimally
affected.”

• H18 states the findings and conclusions of two different studies, References 5 and 23. Both note an increase for LD.
One study concluded the increase was clinically significant at two hours and the other concludes the increase to be
minimal at 72 hours. The area committee’s position is to be conservative in its recommendations.

Section 6.1.1.3, Chilled Specimens (2 to 8 ˚C)

8. The examples are incorrect: only ammonia needs to be collected on ice.

• According to Reference 37, the examples are correct. If recent or future studies indicate that a particular
requirement for a specific analyte is no longer necessary, a laboratory should document its procedure in its
laboratory.

Section 6.1.1.4, Metabolic Inhibitors and Preservatives

9. The third sentence of the second paragraph states, “Microcollection devices containing a suitable antiglycolytic agent should
be used for pediatric blood glucose collection.” I suggest changing to “may be used,” since there are no published data to
demonstrate that there is a difference if other devices are used.

• The text has been revised as follows: “Microcollection devices containing a suitable antiglycolytic agent may be used
for pediatric blood glucose collection.”

Section 6.1.2, Transportation

10. Lacks information on leak proof/screw caps of the transfer tubes.

• The text has been revised as follows: “Secondary tubes must be leak-proof” has been added after the third sentence
in Section 6.1.2.2.1, Remote Collection Sites.

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 Volume 24 H18-A3

Sections 6.1.2.1.2, Tube Orientation, and 6.1.2.2.1, Remote Collection Sites

11. Blood tubes do not need to be vertical. All pneumatic tube systems will have random orientations. We have done extensive
checks of pneumatic tubes and found no degradation for nearly all analytes. This requirement will cause unnecessary cost
and complexity and is not consistent with Section 6.1.2.3.

• The text has been revised as follows in Section 6.1.2.1.2: “Where possible, tubes of blood should be kept in a vertical,
closure-up position.”

Sections 6.1.2.2.1, Remote Collection Sites, and 6.3.1.1, Serum/Plasma Contact with Cells/Clot

12. A maximum limit of two hours is unrealistic for most hospitals. We use three hours which is met most of the time. There
are exceptions which require special handling. There are few analytes that are not stable in whole blood for three hours; see
Zhang, et al. Effect of serum-clot contact time on clinical chemistry laboratory results. Clin Chem. 1998;44:1325-1333.

• Two hours (Reference 5) to three hours (Reference 31) must be adhered to for glucose and/or potassium. The
different studies described under Section 6 are intended to guide the readers of H18-A3 to make informed decisions
for their laboratories. When glucose and/or potassium are ordered along with more stable analytes in the same
collection tube, the shorter stability times dictate the timeline. The area committee’s position is to be conservative in
its recommendations.

The text has been revised as follows in Section 6.1.2.2.1: “The stability of the specimen dictates conditions for
transport from remote collection sites (e.g., physician’s offices, satellite draw stations) to the testing location. If an
uncentrifuged whole blood specimen is to be sent to a laboratory for testing, it must reach the laboratory in time to
be processed with serum/plasma separation occurring in a time limit to protect the stability of the analytes. If this
requirement cannot be met, the specimen must be centrifuged at the collection site with the serum or plasma
separated from the cells and held under appropriate conditions (see Section 6.3) until it can be delivered to the
laboratory…Specific handling and processing requirements published by the testing laboratory should also be
consulted.”

Section 6.1.2.3, Automated Delivery Systems

13. Recommend how many specimens and a statistical test to be used for a parallel study to qualify a pneumatic tube system.

• The area committee recommends that the references cited in H18 for pneumatic tube systems be reviewed for how
the authors studied these systems as to the number of test comparisons and the statistical tests employed.

14. In second paragraph, second sentence: “in under-filled tubes.” This is confusing. Tubes should be properly filled, especially
coagulation tubes. Is the document referring to partial draw tubes? Either way, it should be rephrased since “under-filled” is
unclear and potentially misleading.

• The document is not referring to partial draw tubes but to improperly filled or “short-draw” tubes that lead to the
alteration of the blood to additive ratio. The text has been revised as follows: “This is especially important for
heparin management by APTT in tubes that are not optimally filled, since a progressive shortening of the heparin
APTT value in part related to platelet-released neutralizing substances has the potential to lead to over-
anticoagulated patients.”

Section 6.1.3.1, Time

15. In the second sentence, add five minutes (reflects clotting time with thrombin). Also add, “see manufacturer’s
recommendations” since the clot time of additives listed vary significantly. Correct (see Section 6.1.1.1) to (see Section
6.1.1.2) for plasma reference.

• The text has been revised as follows: “Blood collected using a tube containing a clotting activator (e.g., thrombin,
silica, or glass particles) can be processed as early as 5 to 30 minutes after the blood is drawn. Anticoagulated
specimens can be centrifuged immediately (see Sections 6.1.1.1 for serum and 6.1.1.2 for plasma). Also refer to
manufacturers’ specific recommendations.”

Section 6.1.3.5, Criteria for Specimen Rejection

16. Add “with facility policy” after “consulted for recommended labeling requirements” in the second paragraph.

• The text has been revised as follows: “The most current edition of NCCLS document H3—Procedures for the
Collection of Diagnostic Blood Specimens by Venipuncture should be consulted for recommended labeling
requirements. In addition, consult facility policy.”
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 Number 38 NCCLS

17. Under the Hemolysis bullet point, only Section 6.1.2.1.3 is specifically written for hemolysis.

• The text has been revised to refer the reader to Section 6.1.2.1.3.

Section 6.2.2.1, Recommendations

18. Temperature-controlled centrifuges are not necessary for many analytes. The text should be modified to indicate “for
temperature-sensitive analytes.”

• The text has been revised as follows: “Laboratories should have temperature-controlled centrifuges for temperature-
sensitive analytes. Centrifuges can generate internal heat that may be inappropriate for analyte stability (e.g.,
coagulation studies). Specific thermolabile analytes should be separated at 4 oC (e.g., ACTH, cyclic-AMP).”

Section 6.2.2.2, Chilled Specimens

19. Potassium should not be measured if the specimen was chilled. Potassium changes in whole blood are dramatic and fast
when temperature is changed. The two hour caution in the text is incorrect. See the reference cited above.

• The area committee believes the recommendation is supported by References 4 and 25.

Section 6.2.3, Recentrifugation

20. The first sentence of the second paragraph should state the findings of the literature search up front. Also, I believe that use
of the word ‘other’ will further clarify that recentrifugation of ‘analytes’ does not include potassium. Either use ‘first and
second centrifugations’ or ‘centrifugation and recentrifugation.’ The last sentence is also too long. Try something like this:

“The working group performed a literature search for the years 1966 to 2004 and found three sources recommending that
potassium should not be recentrifuged. Other analytes were not cited. However, the working group cautions that the
potential for inaccuracy of other analytes is possible. Laboratories may wish to conduct studies when there are unexplained
results seemingly attributable to recentrifugation. For example, when the time between centrifugation and recentrifugation
has been lengthy, as can occur between offsite collection locations and the testing laboratory.”

• Section 6.2.3 has been revised as follows:

6.2.3 Recentrifugation

“Specimens for potassium measurement should not be centrifuged more than once. Results will be falsely increased. 75-78

NOTE: A literature search was performed for the years 1966 to 2004. Four references specifically indicate that
specimens for potassium should not be recentrifuged.75-78 No other analytes were cited. However, the area committee
cautions that the potential for inaccuracy for other analytes is possible. Laboratories may wish to conduct studies
when there are unexplained results possibly attributable to recentrifugation, for example, when the time between
centrifugation and recentrifugation has been lengthy, as can occur between offsite blood collection locations and the
testing laboratory.

Harvesting of additional serum/plasma AFTER serum/plasma has been removed from non-gel or gel tubes SHOULD
NOT be attempted. When serum/plasma has been removed and harvesting of additional serum/plasma is attempted,
the volume ratio of plasma to erythrocytes has been altered. Analytes from cellular leakage/exchange, accentuated by
clot retraction, will then be centrifuged into the serum/plasma used for testing. This can cause erroneous results.”

Section 6.2.3.1, Recentrifuging a Non-Gel Tube with Serum/Plasma in Contact with Cells

21. Unclear. Are you saying that this should not be done? If so, then it should be stated up front. Also, one sentence doesn’t
work. I suggest revising the section as follows:

“Harvesting of additional serum/plasma after serum/plasma has been removed from the non-gel tube SHOULD NOT be
attempted.
If serum/plasma has been removed from the tube and harvesting of additional serum/plasma is attempted, the volume ratio
of plasma water to erythrocytes will be altered. Analytes from cellular leakage/exchange will then be centrifuged into the
serum/plasma used for testing, which may cause erroneous results.”

• Section 6.2.3, Recentrifugation, has been revised (see response to comment 20) and Section 6.2.3.1 has been deleted.

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 Volume 24 H18-A3

Section 6.2.3.2, Recentrifuging a Gel Tube

22. Unclear. Sentence is too long. Don’t understand what is being said. Do you have a recommendation to prevent this or are
you telling the reader to just make sure to watch out for clot retraction?

• Section 6.2.3, Recentrifugation, has been revised (see response to comment 20) and Section 6.2.3.2 has been deleted.

Section 6.3, Postcentrifugation Phase

23. Lack of information on effect of lipemic, hemolyzed, turbid and icteric serum, and effect of heat inactivation on tests used
for determination of IgG/IgM levels for various infectious diseases. No mention of blood sample collection from a cadaver
in the document.

• Postcentrifugation is defined as the time period after the centrifugation of the specimen and before removal of an
aliquot of serum/plasma for testing. Lipemia, hemolysis, icterus, and heat inactivation are testing issues.

Blood collection from cadavers is beyond the scope of this guideline.

Section 6.3.1.2.1, Separated Serum or Plasma

24. First paragraph, fifth sentence, restate (i.e., insert) ‘separated serum’ for clarity.

“At 2 to 8 ˚C and room temperature significant stability of separated serum has been observed for 2 to 14 days.”

Also, a question on room temperature. A 20-25 ˚C range for room temperature is given, but then there is a statement about
instability above 22 ˚C. What does that mean? Is the recommended room temperature then between 20-22 ˚C? If so, take out
20-25 and replace with 20-22 ˚C.

• The following text has been added after the first sentence: “It is the responsibility of the individual laboratory to use
all available references and/or their own studies to determine specific stability criteria for their laboratory.” This
section has been further revised as follows: Two sentences have been added to a new paragraph that reads: “It seems
apparent that an analyte that is stable at room temperature in unseparated serum/plasma should also be stable at the
same temperature for the same length of time in separated serum/plasma…Based on the studies cited, this guideline
makes the following ‘general’ recommendations, recognizing that there can be several exceptions.” The sixth
sentence of this paragraph has been revised to read: “However, room temperature (20 to 25 °C) in the laboratory is a
critical stability parameter with decreased stability observed at temperatures above 22 °C for some analytes.” The
first bullet has been revised to state “room temperature” instead of 22 °C.

20 to 25 °C is generally considered to be room temperature. However, Reference 4 indicates there can be analyte
instability at greater than 22 °C. The reader should consult all of the different references pertaining to temperature.

25. This section contains numerous generalizations that can be misleading and incorrect. Storage conditions to preserve the
integrity of blood and serum specimens vary with the analyte. The statement “when tubes are stoppered and serum is in
contact with cells” contradicts earlier recommendations in Section 6 to separate serum or plasma from cells within two
(three) hours. The generalizations in the first two bullets on page 13 are not applicable to many situations. I suggest this
section be completely rewritten to emphasize the importance of setting storage conditions for each analyte which meets its
requirements for stable storage.

• The area committee recognizes that storage conditions can vary with the analyte. This is the reason for the
recommendation that laboratories consult specific references and the manufacturer of tests and collection devices.
This guideline cites several references which indicate that there are many analytes that are stable with serum in
contact with cells. However, there are also several analytes that must be separated from the cells in order to maintain
analyte integrity. We believe it should be the responsibility of the individual laboratory to establish its own specific
handling policy for different analyte stabilities based on the available science.

Section 6.3.1.2.1 has been revised. See response to comment 24.

Section 7.1.1.2, Function

26. An important technical detail needs to be added. Gel barrier tubes should never be respun because serum or plasma that has
been in contact with the cells will be expressed into the serum above the barrier. This can lead to serious interference from
potassium, phosphate, AST, LDH, etc., which have leaked from the red cells.

• This information can be found in Section 6.2.3, Recentrifugation.

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 Number 38 NCCLS

27. Sentences 7 and 8 conflict with sentence 6. I recommend keeping sentences 7 and 8, and deleting sentence 6.

• The text has been revised as follows: “When using a fixed-angle centrifuge, and if serum is to be stored on the gel,
visual inspection of the tube is necessary to check for completeness of the barrier. Barrier formation is more
predictable with swing-bucket centrifuges. However, the gel should be checked for barrier integrity.”

Section 7.1.1.3, Storage

28. Serum can be stored on gel barriers for several days at 4 ˚C without affecting most analytes. The text should not be so
inflexible in stating only up to 24 hours since there is no literature to support that limitation.

• The text has been revised as follows: “In general, serum can be stored on the gel for up to 48 hours at 4 oC.” Two
references have also been added at the end of this sentence. The sentence recommending that tubes should be kept in
a vertical closure-up position has been deleted.

Some older references (References 82 and 83) indicate two to five days. The number of methods and analytes studied
ranged from few to many. As indicated in the guideline, device manufacturers should be consulted for more current
stability information. The individual laboratory may also wish to conduct its own stabilities study.

29. Discrepancy for serum storage. This section states up to 24 hours at 4 ˚C (referenced), while Section 7.1.3.1.2 states that
serum may be stored for up to 48 hours (no reference).

• The text has been revised for consistency as described in the response to comment 28.

Section 7.1.3.1.2, Function

30. Add a reference for storage at 48 hours. The recommendation conflicts with storage time in Section 7.1.1.3.

• Section 7.1.3.1.2 refers to a nonintegrated gel device. The original manufacturer’s documentation indicated 48 hours.
Section 7.1.1.3 has been revised to 48 hours for integrated gel tube systems. See response to comment 28.

31. Add “prior to centrifugation” after “A suitable tube closure is placed on the tube.” Or move the fourth sentence in Section
7.1.3.2.1 to the end of 7.1.3.1.2.

• The text has been revised as follows: “Serum can be stored on the gel for up to 48 hours. If serum is to be stored, the
gel should be visually inspected for barrier integrity and a suitable closure should be placed on the tube after the
device has been removed from the tube.”

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 Number 38 NCCLS

The Quality System Approach

NCCLS subscribes to a quality system approach in the development of standards and guidelines, which facilitates
project management; defines a document structure via a template; and provides a process to identify needed
documents. The approach is based on the model presented in the most current edition of NCCLS document HS1—A
Quality Management System Model for Health Care. The quality system approach applies a core set of “quality
system essentials” (QSEs), basic to any organization, to all operations in any healthcare service’s path of workflow
(i.e., operational aspects that define how a particular product or service is provided). The QSEs provide the
framework for delivery of any type of product or service, serving as a manager’s guide. The quality system
essentials (QSEs) are:

Documents & Records Equipment Information Management Process Improvement

Organization Purchasing & Inventory Occurrence Management Service & Satisfaction
Personnel Process Control Assessment Facilities & Safety

H18-A3 addresses the quality system essentials (QSEs) indicated by an “X.” For a description of the other NCCLS
documents listed in the grid, please refer to the Related NCCLS Publications section on the following page.
Purchasing &

Improvement
Organization

Management

Management
Information

Satisfaction
Assessment

Facilities &
Occurrence
Documents

Equipment
& Records

Service &
Personnel

Inventory

Control
Process

Process

Safety
H1 X H3
H3 H3 M29
Adapted from NCCLS document HS1—A Quality Management System Model for Health Care.

Path of Workflow

A path of workflow is the description of the necessary steps to deliver the particular product or service that the
organization or entity provides. For example, NCCLS document GP26—Application of a Quality Management
System Model for Laboratory Services defines a clinical laboratory path of workflow which consists of three
sequential processes: preanalytic, analytic, and postanalytic. All clinical laboratories follow these processes to
deliver the laboratory’s services, namely quality laboratory information.

H18-A3 addresses the clinical laboratory path of workflow steps indicated by an “X.” For a description of the other
NCCLS documents listed in the grid, please refer to the Related NCCLS Publications section on the following page.

Preanalytic Analytic Postanalytic

Interpretation

Management
Test Request
Assessment

Laboratory
Collection
Specimen

Specimen

Specimen

Specimen
Transport

Post-test
Receipt

Review
Testing

Results
Patient

Report

H3 H3 H3 X X
H4 H3 H3
H11 H4
H21 H11
H21
Adapted from NCCLS document HS1—A Quality Management System Model for Health Care.

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 Volume 24 H18-A3

Related NCCLS Publications*

C31-A2 Ionized Calcium Determinations: Precollection Variables, Specimen Choice, Collection, and Handling;
Approved Guideline—Second Edition (2001). This document addresses preanalytical considerations—such
as patient condition, specimen choice, collection, and handling—that can influence accuracy and clinical
utility of ionized calcium measurements.

H1-A5 Tubes and Additives for Venous Blood Specimen Collection; Approved Standard—Fifth Edition (2003).
This standard contains requirements for blood collection tubes and additives including heparin, EDTA, and
sodium citrate.

H3-A5 Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard—
Fifth Edition (2003). This document provides procedures for the collection of diagnostic specimens by
venipuncture, including line draws, blood culture collection, and venipuncture in children.

H4-A5 Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens; Approved
Standard—Fifth Edition (2004). This document provides a technique for the collection of diagnostic
capillary blood specimens, including recommendations for collection sites and specimen handling and
identification. Specifications for disposable devices used to collect, process, and transfer diagnostic capillary
blood specimens are also included.

H11-A4 Procedures for the Collection of Arterial Blood Specimens; Approved Standard—Fourth Edition
(2004). This document provides principles for collecting, handling, and transporting arterial blood specimens
to assist with reducing collection hazards and ensuring the integrity of the arterial specimen.

H21-A4 Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation
Assays; Approved Guideline—Fourth Edition (2003). This document provides procedures for collecting,
transporting, and storing blood; processing blood specimens; storage of plasma for coagulation testing; and
general recommendations for performing the tests.

M29-A2 Protection of Laboratory Workers from Occupationally Acquired Infections; Approved Guideline—
Second Edition (2001). Based on U.S. regulations, this document provides guidance on the risk of
transmission of hepatitis viruses and human immunodeficiency viruses in any laboratory setting; specific
precautions for preventing the laboratory transmission of blood-borne infection from laboratory instruments
and materials; and recommendations for the management of blood-borne exposure.

*
Proposed- and tentative-level documents are being advanced through the NCCLS consensus process; therefore, readers should
refer to the most recent editions.
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NOTES

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 Number 38 NCCLS

NOTES

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 Number 38 NCCLS

NOTES

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Hôpital du Sacré-Coeur de Massachusetts General Hospital Edward Island, Canada) The Toledo Hospital (OH)
Montreal (Montreal, Quebec, (Microbiology Laboratory) Queensland Health Pathology Touro Infirmary (LA)
Canada) MDS Metro Laboratory Services Services (Australia) Tripler Army Medical Center (HI)
Hôpital Maisonneuve - Rosemont (Burnaby, BC, Canada) Quest Diagnostics Incorporated Truman Medical Center (MO)
(Montreal, Canada) Medical College of Virginia (CA) UCLA Medical Center (CA)
Hôpital Saint-Luc (Montreal, Hospital Quintiles Laboratories, Ltd. (GA) UCSF Medical Center (CA)
Quebec, Canada) Medical University of South Regions Hospital UNC Hospitals (NC)
Hospital Consolidated Laboratories Carolina Rex Healthcare (NC) Unidad de Patologia Clinica
(MI) Memorial Medical Center Rhode Island Department of Health (Mexico)
Hospital for Sick Children (Toronto, (Napoleon Avenue, New Orleans, Laboratories Union Clinical Laboratory (Taiwan)
ON, Canada) LA) Riverside Medical Center (IL) Universita Campus Bio-Medico
Hospital de Sousa Martins (Portugal) Memorial Medical Center (Jefferson Robert Wood Johnson University (Italy)
Hotel Dieu Grace Hospital (Windsor, Davis Pkwy., New Orleans, LA) Hospital (NJ) University College Hospital
ON, Canada) Methodist Hospital (Houston, TX) Royal Columbian Hospital (New (Galway, Ireland)
Huddinge University Hospital Methodist Hospital (San Antonio, Westminster, BC, Canada) University of Alabama-Birmingham
(Sweden) TX) Sahlgrenska Universitetssjukhuset Hospital
Hunter Area Health Service Michigan Department of (Sweden) University of Chicago Hospitals
(Australia) Community Health St. Alexius Medical Center (ND) (IL)
Indiana University Mid America Clinical Laboratories, St. Anthony Hospital (CO) University of Colorado Hospital
Innova Fairfax Hospital (VA) LLC (IN) St. Anthony’s Hospital (FL) University of Debrecen Medical
Institute of Medical and Veterinary Middlesex Hospital (CT) St. Barnabas Medical Center (NJ) Health and Science Center
Science (Australia) Monmouth Medical Center (NJ) St. Christopher’s Hospital for (Hungary)
International Health Management Montreal Children’s Hospital Children (PA) University of Illinois Medical Center
Associates, Inc. (IL) (Canada) St-Eustache Hospital (Quebec, University of Maryland Medical
Jackson Memorial Hospital (FL) Montreal General Hospital (Canada) Canada) System
Jacobi Medical Center (NY) National Serology Reference St. John Hospital and Medical University of the Ryukyus (Japan)
John C. Lincoln Hospital (AZ) Laboratory (Australia) Center (MI) University of Wisconsin Hospital
Johns Hopkins Medical Institutions NB Department of Health & St. John’s Hospital & Health Center The University of Texas Medical
(MD) Wellness (New Brunswick, (CA) Branch
Kadlec Medical Center (WA) Canada) St. Joseph Mercy Hospital (MI) The University of the West Indies
Kaiser Permanente (MD) The Nebraska Medical Center St. Joseph’s Hospital – Marshfield University of Virginia Medical
Kangnam St. Mary’s Hospital New Britain General Hospital (CT) Clinic (WI) Center
(Korea) New England Fertility Institute (CT) St. Jude Children’s Research University of Washington
Kantonsspital (Switzerland) New England Medical Center (MA) Hospital (TN) USA MEDDAC-AK
Kenora-Rainy River Regional New York City Department of St. Mary of the Plains Hospital US LABS, Inc. (CA)
Laboratory Program (Ontario, Health & Mental Hygiene (TX) UZ-KUL Medical Center (Belgium)
Canada) NorDx (ME) St. Michael’s Hospital (Toronto, VA (Hampton) Medical Center (VA)
Kimball Medical Center (NJ) North Carolina State Laboratory of ON, Canada) VA (Tuskegee) Medical Center
King Abdulaziz Medical City – Public Health Ste. Justine Hospital (Montreal, PQ, (AL)
Jeddah (Saudi Arabia) North Central Medical Center (TX) Canada) Valley Children’s Hospital (CA)
King Faisal Specialist Hospital North Shore - Long Island Jewish Salem Clinic (OR) Virginia Beach General Hospital
(Saudi Arabia) Health System Laboratories (NY) San Francisco General Hospital (VA)
LabCorp (NC) North Shore University Hospital (CA) Virginia Department of Health
Laboratoire de Santé Publique du (NY) Santa Clara Valley Medical Center Virginia Regional Medical Center
Quebec (Canada) Northwestern Memorial Hospital (CA) (MN)
Laboratorio Dr. Echevarne (Spain) (IL) Seoul Nat’l University Hospital ViroMed Laboratories (MN)
Laboratório Fleury S/C Ltda. Ochsner Clinic Foundation (LA) (Korea) Washington Adventist Hospital
(Brazil) O.L. Vrouwziekenhuis (Belgium) Shands at the University of Florida (MD)
Laboratorio Manlab (Argentina) Ordre professionnel des South Bend Medical Foundation Washoe Medical Center
Laboratory Corporation of America technologists médicaux du (IN) Laboratory (NV)
(NJ) Québec South Western Area Pathology Waterford Regional Hospital
LAC and USC Healthcare Orlando Regional Healthcare System Service (Australia) (Ireland)
Network (CA) (FL) Southern Maine Medical Center Wellstar Health Systems (GA)
Lakeland Regional Medical Center Ospedali Riuniti (Italy) Spartanburg Regional Medical West Jefferson Medical Center (LA)
(FL) The Ottawa Hospital Center (SC) Wilford Hall Medical Center (TX)
Landstuhl Regional Medical Center (Ottawa, ON, Canada) Specialty Laboratories, Inc. (CA) William Beaumont Army Medical
(APO AE) OU Medical Center (OK) State of Connecticut Dept. of Public Center (TX)
LeBonheur Children’s Medical Our Lady of the Resurrection Health William Beaumont Hospital (MI)
Center (TN) Medical Center (IL) State of Washington Department of William Osler Health Centre
Lewis-Gale Medical Center (VA) Pathology and Cytology Health (Brampton, ON, Canada)
L'Hotel-Dieu de Quebec (Canada) Laboratories, Inc. (KY) Stony Brook University Hospital Winn Army Community Hospital
Libero Instituto Univ. Campus Pathology Associates Medical (NY) (GA)
BioMedico (Italy) Laboratories (WA) Stormont-Vail Regional Medical Winnipeg Regional Health
Loma Linda Mercantile (CA) Peking University Shenzhen Center (KS) Authority (Winnipeg, Canada)
Long Beach Memorial Medical Hospital (China) Sun Health-Boswell Hospital (AZ) Wishard Memorial Hospital (IN)
Center (CA) The Permanente Medical Group Sunnybrook Health Science Center Yonsei University College of
Louisiana State University (CA) (ON, Canada) Medicine (Korea)
Medical Center Piedmont Hospital (GA) Sunrise Hospital and Medical Center York Hospital (PA)
Lourdes Hospital (KY) Pocono Medical Center (PA) (NV)

OFFICERS BOARD OF DIRECTORS

Thomas L. Hearn, Ph.D., Susan Blonshine, RRT, RPFT, FAARC Willie E. May, Ph.D.
President TechEd National Institute of Standards and Technology
Centers for Disease Control and Prevention
Kurt H. Davis, FCSMLS, CAE Gary L. Myers, Ph.D.
Robert L. Habig, Ph.D., Canadian Society for Medical Laboratory Science Centers for Disease Control and Prevention
President Elect
Abbott Laboratories Mary Lou Gantzer, Ph.D. Klaus E. Stinshoff, Dr.rer.nat.
Dade Behring Inc. Digene (Switzerland) Sàrl
Wayne Brinster,
Secretary Lillian J. Gill, M.S. James A. Thomas
BD FDA Center for Devices and Radiological Health ASTM International

Gerald A. Hoeltge, M.D., Carolyn D. Jones, J.D., M.P.H. Kiyoaki Watanabe, M.D.
Treasurer AdvaMed Keio University School of Medicine
The Cleveland Clinic Foundation
J. Stephen Kroger, M.D., MACP Judith A. Yost, M.A., M.T.(ASCP)
Donna M. Meyer, Ph.D., COLA Centers for Medicare & Medicaid Services
Immediate Past President
CHRISTUS Health

Glen Fine, M.S., M.B.A.

Executive Vice President

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Licensed to: Olga Sergeeva

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