QUALITY ASSURANCE

A. Definitions
 Quality
 Meeting pre-determined requirements for user
 “fitness for purpose”
 “do it right the first time”
 ISO: Totality of characteristics of an entity that bear on its ability to satisfy stated and implied needs

 Quality Assurance
 The activity of providing evidence needed to establish confidence among all concerned, that quality-related activities are
being performed effectively
 An established protocol of policies and procedures for all laboratory actions performed to ensure the quality of services
rendered—Includes all phases of laboratory testing (Pre-analytical phase, Analytical phase ,and Post-analytical phase)

B. Preanalytical
 Include: Test Request, patient Preparation, specimen collection, handling, storage and preservation

 Requisition Form:
 Information must match that of the specimen label
 Includes:
 Patient identification information (name, sex, age, date of birth)
 Type of urine specimen
 Actual date and time of collection
 Time of specimen receipt and testing
 Tests requested
 Requesting physician

 Patient Preparation:
 Patients are instructed regarding methods of proper collection
 Special Instructions: Fasting, avoid certain drugs

 Specimen Collection:
 Standard precautions
 Personal protective equipment
 Specimen container
 Clean, dry, leak-proof, disposable, screw-top, wide mouth, wide flat bottom, clear material, 50 mL
 Specimen label
 Attached to the body, not the lid
 Patient’s name and identification number
 Date and time of collection
 Additional information (Patient’s age & location, Physician’s name)

 Specimen Rejection:
 Improperly labeled
 Improperly collected
 Improperly transported
 Nonmatching information
 Contaminated sample
 Insufficient volume

 Specimen Integrity:
 Test for creatinine and urea levels: A higher urea and creatinine content can identify a fluid as urine
 Specimen should be delivered and tested within 2 hours
 In case of delays, samples must be:
 Refrigerated or preserved
 Protected from light
  Changes in Unpreserved Urine:
Analyte/Component Change Cause
Color Darkened/Modified Oxidation or reduction of metabolites
 Bilirubin (yellow)  Biliverdin (green)
 Hemoglobin (red)  Methemoglobin (brown)
 Urobilinogen (colorless)  Urobilin (yellow orange)
Clarity/Turbidity Decreased Crystal (Amorphous urates/phosphates) precipitation
Bacterial proliferation
Odor Ammoniacal, Foul smelling Bacterial growth
Bacterial conversion of urea to NH3
pH Increased Breakdown of urea NH3 by urease producing bacteria
Loss of CO2
Decreased Bacterial or yeast conversion of glucose to metabolic acids
Glucose Decreased Glycolysis
Bacterial use
Ketones Decreased Volatilization of acetone
Bacterial metabolism
Bilirubin Decreased Exposure to light/photo oxidation to biliverdin
Urobilinogen Decreased Oxidation to urobilin
Nitrite Increased Multiplication of nitrate reducing bacteria
Decreased Conversion to nitrogen
RBCs, WBCs, Casts Decreased Disintegration in dilute alkaline urine
Bacteria Increased Exponential proliferation

 Preservatives
Urine Preservatives
Type Advantages Disadvantages Use
Refrigeration Acceptable for routine urinalysis Precipitates amorphous and/or Storage before and after
for 24 hours crystalline solutes testing
Acceptable for urine culture;
inhibits bacterial growth for
≈24 hours
Inexpensive
Commercial transport Acceptable for routine urinalysis; pH and SG may be altered; varies Urine transport from off-site
tubes (see Table below) preserves chemical and formed with tube used to laboratory
elements in urine at room Can interfere with chemistry Preserve specimen at room
temperature tests (e.g., sodium, potassium, temperature for longer
Boric acid preservative is also hormone, drug assays) time period; varies with
acceptable for urine culture tube used
Thymol Preserves sediment elements Interferes with protein Sediment preservation
(e.g., casts, cells) precipitation tests
Inhibits bacterial and yeast In high concentration, can
growth precipitate crystals
Formalin Excellent cellular preservative False-negative reagent strip tests Cytology
for blood and urobilinogen

Saccomanno’s fixative Excellent cellular preservative Potential chemical hazard Cytology

Commercially available and
inexpensive
Acids (HCl, glacial acetic Inexpensive Unacceptable for urinalysis For quantitative analysis of
acid) Stabilizes calcium, phosphorus, testing urine solutes, such as
steroids, hormones, etc. Potential chemical hazard steroids, hormones, etc.

Sodium carbonate Inexpensive Unacceptable for urinalysis For quantitative analysis of

Stabilizes porphyrins, testing porphyrins,
porphobilinogen, etc. porphobilinogen, etc.
 Commercial Urine Transport Tubes With Preservative
Tube Preservative and Use Comments
Additives
Plastic conical tube; Chlorhexidine Urinalysis Stabilizes urine for up to 72 hours at room
yellow and cherry red Ethyl paraben Bactericidal; not temperature
marble stopper Sodium propionate acceptable for urine Conical bottom designed to fit Kova-
culture pettors
Plastic conical tube; Dowicil 200 (a Urinalysis Stabilizes urine for up to 96 hours at room
yellow plastic cap formaldehyde releasing Bactericidal; not temperature
agent) acceptable for urine No change in pH or SG
Mannitol culture
Polyethylene glycol
Glass tube; gray stopper Boric acid Urinalysis Stabilizes urine for up to 48 hours at room
Sodium formate Urine culture and temperature
D-Sorbitol sensitivity pH adjusted to 6 to 7
Sodium acetate Can be used for urinalysis SG increased by ≈0.006 to 0.0078
Bacteriostatic

C. Analytical
 Testing proper
 Include: reagents, instrumentation and equipment, standard operating procedures, quality control, competency of
personnel

 Reagents:
 Reagent strips
 Checked against known negative and positive control solutions on each shift, at a minimum of once a day or
whenever a new bottle is opened
 Protected from moisture, chemicals, heat, and light
 Discard strips if they show signs of deterioration, contamination, or if improperly stored
 Containers: Tight fitting lids, desiccants or drying agents, black in color
 Color chart printed on label must be protected from fading
 Storage Temp: below 30˚C

 Instrumentation and Equipment:

 Centrifuge
 Calibration is done every 3 months using a tachometer
 Disinfection is done weekly

 Standard Operating Procedures:

 Must always be available and must comply with CLSI guidelines
 Include: All Procedures, proper specimen collection and handling, reagent preparation, reporting of results, references

D. Postanalytical
 Reporting of Results:
 Standardized reporting format
 Reference ranges
 Critical values relayed immediately
 Pathologic crystals like cysteine, leucine, tyrosine
 Strong positive for glucose and ketones
 Reducing substances in an infant
 URINE SPECIMEN TYPES, COLLECTION, AND PRESERVATION

 Why Study Urine?

 Fluid biopsy of the kidney
 “fountain” of information
 Ultrafiltrate of the plasma
 Readily obtainable

 Specimen Types

Collection Advantages Disadvantages Uses

First Morning Specimen Concentrated High salt Routine screening
Patient voids before going to bed Stability of formed concentration To confirm postural or
Patient collects the first urine voided in the morning elements Inconvenient orthostatic proteinuria
collection Cytology studies
Random Urine Specimen Ease and May not be accurate Routine screening
Urine collected at any time convenience Cytology studies (with
prior hydration)
Routine screening (no prior patient preparation) Fluid deprivation tests

Cytology studies (prior hydration)

Patient drinks 24-32 oz of water each hour for 2
hours
*Multiple collections (3-5 consecutive days)
**Exercise 5 minutes prior to collection

Timed Collection Can compensate for Requires accurate Quantitative chemical

2 Types: circadian or timing and strict analysis
1. Predetermined length of time diurnal variations adherence to Clearance tests
directions Cytology studies
2. Specific time of day May need the Evaluation of fistula
addition of
Collection Protocol: preservatives

At start time (e.g., 7 AM)

Patient empties bladder into toilet
Subsequent urine throughout timed interval is
collected in the container

At end time (e.g., 7 AM)

Patient empties bladder into collection container

*In the laboratory: sample is mixed well and the

volume measured and recorded
**An aliquot (≈ 50 mL) is used for testing (remainder
is discarded)

OTHERS:
12- hour urine for ADDIS COUNT
- Addis count used a hemocytometer to count the number of RBCs, WBCs, casts and epithelial cells present in a
12-hour urine sample

Early afternoon specimen (2 PM urine/ 2 PM – 4 PM urine)

- Utilized for urobilinogen determination
 Collection Techniques

Collection Technique Use

Routine Void Routine screening
No preparation before collection

Midstream Clean Catch Bacterial and fungal cultures

Genital area cleansed before collection (sterile container required)
Patient passes initial urine into toilet, stops and collects urine in container, then empties any Routine screening
additional urine into toilet Cytology

Catheterized, urethral Bacterial and fungal cultures

A catheter is inserted into the bladder via the urethra Routine screening
Urine flows directly from bladder through catheter into plastic bag

Catheterized, ureteral To differentiate kidney

A catheter is inserted through the urethra and bladder to collect urine directly from the left infections
and/or right ureters

Suprapubic aspiration Bacterial and fungal cultures

Using sterile needle and syringe, the abdominal wall is punctured, and urine is directly aspirated
from the bladder

Pediatric collection Routine screening

Used with patients unable to urinate voluntarily Quantitative assays
Plastic collection bag is adhered to the skin surrounding the genital area
Urine accumulates in plastic bag

 Is This Fluid Urine?

 Urea & Creatinine
 A HIGHER UREA AND CREATININE content can identify a fluid as urine
 Urine concentrations
 Strasinger:
 Urea: 25 -35 g/ 24 hr
 Creatinine: 1.5 g/ 24 hr
 Bishop:
 Blood Urea Nitrogen: 12-20 grams/ 24 hours
 Creatinine
 Male: 800-2000 mg/24 hours
 Female: 600-1800 mg/24 hours

***Serum Concentrations
 Bishop
 Blood Urea Nitrogen: 6-20 mg/dL
 Creatinine
 Male: 0.9-1.3 mg/dL (Jaffe Method)
 Female: 0.6 -1.1 mg/dL (Jaffe Method)
 Other sources:
 Urea: 2.5-10.7 mmol/L
 Creatinine: 62-106 µmol/ L (0.062 -0.106 mmol/L)

 Specific gravity
 Normal urine specific gravity: 1.003 to 1.035
 24-hour urine samples: 1.015 – 1.025
 Specific gravity < 1.003: Probably NOT urine
 Specific gravity > 1.035: Radiographic contrast media
 **Radiographic contrast media is injected to a patient to improve the visibility of internal organs and structures in
X-ray-based imaging techniques. Radiographic contrast media is typically excreted by a patient via urination.
 pH
 pH values greater than 8.0 and less than 4.5 are physiologically impossible
 A urine pH > 9.0 indicates an improperly preserved urine sample.

 Drug Testing
 Chain of Custody: Standardized form that must document and accompany the sample during every step of drug testing,
from collector  courier  laboratory  medical review officer  employer/ requesting office
 Forms of tampering the specimen include substitution, adulteration, or dilution
 Urine specimen collections may be “witnessed” of “unwitnessed”. For “unwitnessed” collection, a waterless urinal
should be used.
The collector can add BLUING AGENT (dye) to the toilet water reservoir to prevent an adulterated specimen
 Quality control:
 Volume: 30-45 mL
 Temperature: 32.50C to 37.70C (should have been submitted within 4 minutes after collection)
 Color: Inspected to identify any signs of contaminants