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1 To advance slide, click anywhere on blank area of screen. This slide presentation is provided to you as an educational service by: Loyola Medical Laboratories - Outreach Services Loyola University Health System This presentation should not be used or copied without the express permission of Loyola Medical Laboratories. Hemoccult Cards for Fecal Occult Blood Training Presentation
2 Hemoccult Cards for Fecal Occult Blood To advance slide, click anywhere on blank area of screen. the availability of written procedures and helpful information This presentation was designed to provide an understanding of: how to correctly perform the Hemoccult test the quality control requirements for the test the limitations of the test (what can cause an inaccurate result) how sample collection is performed
3 Hemoccult Cards for Fecal Occult Blood If you have access to speakers, please turn them on; they will enhance the presentation. If not, the presentation will not be affected. To open presentation to full screen, click on the middle button in the upper most right corner of the box. To advance slide, click anywhere on blank area of screen. To end show, click on the box containing the x in the upper right hand corner of the screen.
4 Hemoccult Cards for Fecal Occult Blood What is occult blood in fecal samples? The word occult means hidden, so occult blood is blood that can be found in fecal specimens but may not be obvious to the naked eye. The easiest way to find out if there is blood in a fecal specimen is to perform a test for occult blood using a Hemoccult card.
5 Hemoccult Cards for Fecal Occult Blood The Hemoccult fecal occult blood test card
6 Hemoccult Cards for Fecal Occult Blood How the test works Hemoccult cards test for occult blood in fecal material. When the oxygen carrying molecule called hemoglobin found in red blood cells reacts with two chemicals guaiac and hydrogen peroxide, a blue compound is formed. You will notice that inside each card, there is a thin layer of paper to which the sample is applied. This paper is made with a special natural resin called guaiac.The fecal sample is applied to this paper and allowed to soak in. Then, the card is turned over and the other chemical, hydrogen peroxide (in the developer), is dropped onto the paper with the sample and allowed to react. If hemoglobin is present, a blue or blue-green color forms and blood is present in the patients fecal specimen.
7 Guaiac paper Hydrogen peroxide (developer) Hemoccult Cards for Fecal Occult Blood
8 Since hemoglobin is not normally present in feces except in minute amounts, the demonstration of the presence of hemoglobin in feces is an important diagnostic clue that usually implies bleeding within the gastrointestinal tract. The Hemoccult test is a rapid, convenient, and qualitative method for detecting fecal occult (hidden) blood which may be indicative of gastrointestinal disease. Clinical significance Hemoccult Cards for Fecal Occult Blood
9 The Hemoccult test is not a direct test for colorectal cancer or any other specific disease. It is recommended as a diagnostic aid during routine physical examinations, to monitor for bleeding in patients with iron deficiency anemia or recuperating from surgery, peptic ulcer, ulcerative colitis and other conditions, and in screening programs for colorectal cancer when patient instructions are followed. Hemoccult tests are designed for preliminary screening as an aid to diagnosis. They are not intended to replace other diagnostic procedures such as sigmoidoscopy, colonoscopy, barium enema, or other x-ray studies. Clinical significance Hemoccult Cards for Fecal Occult Blood
10 Collection Hemoccult Cards for Fecal Occult Blood or: 2) collected at home in a transportable container and brought to the lab, clinic or satellite facility. Collection of a fecal specimen for an occult blood test is generally performed in one of three ways: 1) collected at home by the patient, applied to the cards provided by their physician, and mailed back to the lab or office for testing or: 3) collected in a physicians office during a physical exam and tested immediately by applying to a Hemoccult card.
11 Hemoccult Cards for Fecal Occult Blood Home Collection To increase the chances of detecting occult blood in fecal samples, patients are generally given an occult blood kit. This kit should include 3 individual cards (two samples) each, collecting sticks, a special diet to follow, instructions on how to collect the sample, a special foil mailing envelope and an informational pamphlet about the test and colorectal cancer. When handing out the occult blood cards, patients should be given information on how to collect the specimen and how to return the finished cards to the lab or office.
12 Hemoccult Cards for Fecal Occult Blood Home Collection - Supplies needed Special Diet Stool collection device
13 Hemoccult Cards for Fecal Occult Blood Home Collection Instructions When handing out Hemoccult cards to patients, staff should provide the following instructions to the patient to ensure that the Hemoccult cards are prepared properly for testing: The cards should be prepared one each day for three days or from three separate bowel movements. This increases the chances that occult blood will be found in one of the fecal specimens. Cards should be kept away from humidity and household chemicals.
14 Hemoccult Cards for Fecal Occult Blood When applying the fecal material to the card, the material should be taken from the inside of the stool specimen to avoid picking up blood from hemorrhoids. Fecal material to be applied to cards should be collected with either 1) a special plastic collection container provided by the lab or office or 2) by placing plastic wrap over the toilet to collect the specimen and then discarding the plastic wrap and specimen in the garbage - do not flush! If other tests are to be performed, the patient may be requested to collect the sample into a transportable container to be brought to the lab. Home Collection Instructions
15 Hemoccult Cards for Fecal Occult Blood Patients should not open the back of the card. Patients should use the card before the expiration date on the back. Patients should return the card to the lab or office within 14 days of applying the specimens to the card. When applying the fecal material to the card, the old adage applies: LESS IS MORE! Applying too much material to the card will make it hard to close, difficult to mail and hard to interpret when the developer is added. Home Collection Instructions When applying the fecal material to each box on the card, fecal material from two separate areas should be applied to each of the two boxes.
16 Hemoccult Cards for Fecal Occult Blood Patients should follow the diet that is included with the cards. For women, specimens should not be collected during or within three days of a menstrual period. The card should be labeled with the patients name and medical record number before returning it through the mail. Home Collection Instructions Fecal specimens should not be collected if hematuria or obvious rectal bleeding, such as from hemorrhoids, is present. The special foil envelope must be used to mail the specimen.
17 Hemoccult Cards for Fecal Occult Blood Patient Preparation - Special Diet In general, patients should be given instructions to avoid certain foods, medications or vitamins which may cause false negative or false positive reactions prior to and during the collection period. This includes: Aspirin like drugs - avoid for 7 days prior to and continuing through the test period unless otherwise directed by their physician. Vitamin C in excess of 250 mg per day - avoid 72 hours prior to collection and during the test period.
18 Hemoccult Cards for Fecal Occult Blood Patient Preparation Red meat (beef, lamb), including processed meats and liver - avoid 72 hours prior to collection and during the test period. Raw fruits and vegetables, especially melons, turnips, horseradish - avoid 72 hours prior to collection and during the test period.
19 Physicians should avoid use of substances during the specimen collection which may interfere with the test. Substances to be avoided because they cause false negative or false positive results are: Hemoccult Cards for Fecal Occult Blood Collection by physician Betadine (providone/iodine) - applied to the anal area can cause false positive results.
20 Using other types of sample types on the Hemoccult cards Hemoccult Cards for Fecal Occult Blood Hemoccult cards are meant to be used with fecal specimens and only fecal specimens. Putting a gastric specimen on a Hemoccult card will result in an inaccurate patient result due to: The low pH of gastric specimens causes a false negative The presence of the drug Tagamet which is used to treat ulcers will cause a false positive If it is necessary to test gastric samples for occult blood, Gastroccult cards should be used which are formulated for use with gastric samples.
21 Training requirements JCAHO regulations require that all staff members performing laboratory testing must have documented training before using the test for patient testing. You will be asked to sign a training checklist at the end of this presentation to document your training for JCAHO. This documentation should be given to your manager or clinical coordinator and maintained indefinitely for JCAHO inspections. In addition, each staff member should be screened for color blindness since reading the Hemoccult cards requires the ability to read a blue-green color. Hemoccult Cards for Fecal Occult Blood
22 Competency requirements Hemoccult Cards for Fecal Occult Blood At this time, no yearly competency is required. However, a review of this presentation, the written procedure or training checklist is strongly recommended on a yearly basis.
23 Quality Control Quality controls are materials that are formulated to check if a test system is performing correctly and that the person who is performing the test is using the proper technique. Manufacturers sometimes build in controls to be read along with the test and/or require external liquid type controls to be tested with their test to check its accuracy. JCAHO requires that two levels of controls (positive & negative) be tested prior to reporting out a patient result. This is required for everyone who performs Hemoccult testing using the Hemoccult cards. Hemoccult Cards for Fecal Occult Blood
24 For the Hemoccult cards, the manufacturer has provided two built-in controls, one positive and one negative. When developed with the Hemoccult developer, these controls will check that the card is functioning correctly and that the developer is working properly. If these controls do not read correctly, there may be something wrong with the card, the developer or with the testers technique. Quality Control Hemoccult Cards for Fecal Occult Blood
25 Performing Quality Control As standard laboratory practice, control materials are tested prior to performing the patient test to check if the test is working properly before using up the patient sample. Occult blood cards are the only exception to this rule since the built-in controls are on the same side of the card as the patient sample. If the controls were tested first, the material that makes the positive control turn blue may run into the patient sample part of the card and make the patient result look positive. Therefore, the patient sample is developed first and then the controls are developed and read. Hemoccult Cards for Fecal Occult Blood
26 Storage and stability of Hemoccult Supplies Hemoccult Cards for Fecal Occult Blood Hemoccult cards are stored at room temperature and are stable until the date stamped on the cards. They should be kept in an area that is not subject to extreme cold, heat or humidity. They should not be stored with chemicals that may react with the guaiac paper. Hemoccult developer is stored at room temperature and is stable until the date stamped on the bottle.
27 Practice testing exercise To perform this virtual Hemoccult test you will need: a Hemoccult card a Hemoccult developer bottle a wooden applicator stick a black waterproof marker a patient fecal specimen (if collected by patient) a Hemoccult training checklist a laboratory waived test result form Take a minute to check over the virtual supplies needed before proceeding. Hemoccult Cards for Fecal Occult Blood
28 Supplies for Virtual Hands-on Test Collection cup
29 Step 1 - Check expiration date on card and recollect if expired. Performing Patient Testing Hemoccult Cards for Fecal Occult Blood John Smith MR# 0101010 If testing a mailed in card: Step 2 - Check that the card is labeled with a patients name, address and/or medical record number.
30 Step 3 - Open back of card and add 2 drops of developer to Box A and Box B Performing Patient Testing Hemoccult Cards for Fecal Occult Blood
31 Step 4 - Watch sample and look for blue or blue green color to develop. Blue or blue green color is a positive result. A green only color is bile - this is considered a negative result. No color indicates a negative result. Positive result Hemoccult Cards for Fecal Occult Blood Performing Patient Testing Result must be read within 60 seconds of adding developer. Do not walk away and come back to read the sample. The blue or blue-green color can appear and then fade quickly.
32 Performing Patient Testing Hemoccult Cards for Fecal Occult Blood John Smith MR# 0101010 If preparing a card from a stool specimen or during a physical exam: Step 1 - Check expiration date on card and replace if card is expired. Step 2 - Label the card with the patients name, address and/or medical record number.
33 Performing Patient Testing Hemoccult Cards for Fecal Occult Blood Step 3 - Add patient sample from container or glove to Box A and to Box B. Step 4 - Close card and wait 3-5 minutes to let sample react with guaiac paper. John Smith MR# 0101010
34 Step 5 - Open back of card and add 2 drops to developer to Box A and Box B Hemoccult Cards for Fecal Occult Blood Performing Patient Testing
35 Step 6 - Watch sample and look for blue or blue green color to develop. Blue or blue green color is a positive result. A green only color is bile - this is considered a negative result. No color indicates a negative result. Positive result Hemoccult Cards for Fecal Occult Blood Performing Patient Testing Result must be read within 60 seconds of adding developer. Do not walk away and come back to read the sample. The blue or blue-green color can appear and then fade quickly.
36 Hemoccult Cards for Fecal Occult Blood Performing required quality control After you have added the developer to your patient samples and read the result, you MUST test the built-in quality controls on the card. For the patient test to be considered valid, the positive and negative controls must be tested and documented along with the patient result. Positive and negative control circles.
37 Hemoccult Cards for Fecal Occult Blood Performing required quality control To test the quality controls, add one drop of developer between the positive and negative circles and wait 10 seconds to read the result.
38 The circle marked + (positive) should turn blue. When this circle turns blue, it indicates that the guaiac paper is active and the developer is performing correctly. Hemoccult Cards for Fecal Occult Blood Performing required quality control Must be blue Must remain colorless. + - The circle marked - (negative) must remain colorless (no blue). Both controls must react correctly for the patient result to be considered valid.
39 Per federal regulations and JCAHO standards, patient results must be documented in the patients medical record along with the testers initials and the results of the controls. Documentation should be performed per your areas protocol. The following options are available: 1. Outpatient and satellites If your area is considered an outpatient or satellite facility, you are allowed to use the Laboratory Waived Testing Outpatient Result Form (see example). The presence of the positive and negative controls along with the patient result can be documented on the form. Documenting quality control and patient results Hemoccult Cards for Fecal Occult Blood
40 Documenting quality control and patient results
41 Hemoccult Cards for Fecal Occult Blood Controls are documented here: Patient results are documented here: Laboratory Waived Testing Outpatient Result Form
42 2. Inpatient units If you work in an inpatient unit, you must document your controls in the nursing or physicians notes using an established protocol. If you have tested the controls and they are acceptable, you must document that fact in this manner along with the patients result: If your controls are acceptable and your patient is negative, write: Blue/negative (positive control was blue & patient was -) If your controls are acceptable and your patient is positive, write: Blue/positive (positive control was blue & patient was +) Hemoccult Cards for Fecal Occult Blood Documenting quality control and patient results
43 Performing patient testing To aid you in performing the Hemoccult test correctly, you will find detailed instructions in the Laboratory Procedure Manual - Waived Tests which is provided to all units who perform occult blood testing. In addition, a color chart demonstrating a positive and negative reaction is available from the lab which can be posted in areas where occult blood cards are read. Hemoccult Cards for Fecal Occult Blood
44 Where to get Technical Help For any information about waived testing procedures performed at your facility, you should consult the Laboratory Procedure Manual - Waived Tests. This is a large, royal blue binder given to all sites who perform waived testing. The Laboratory Procedure Manual for Waived Testing
45 Where to get Technical Help The Laboratory Procedure Manual for Waived Testing The Waived Testing Procedure manual contains: JCAHO regulations Written procedures for each test Required quality assurance for all tests Training checklists for all tests Sample competency logs for maintaining annual competency Helpful articles about CLIA and JCAHO regulations Master quality control logs for all tests Troubleshooting help Supply and ordering information
46 Limitations of the test Hemoccult Cards for Fecal Occult Blood Limitations are reasons that the test result may not be accurate. These can include interfering substances ingested by the patient or picked up when collecting the specimen. Some of these are: Can cause false negative results: Vitamin C in excess of 250 mg/day Excessive amounts of Vitamin C enriched foods (citrus foods and juices) Iron supplements which contain quantities of Vitamin C in excess of 250 mg/day
47 Limitations of the test Hemoccult Cards for Fecal Occult Blood Can cause false positive results: Ingesting red meat (beef, lamb) or processed meats and liver Some raw vegetables or fruit (horseradish, turnips, melons, radishes) when test performed immediately after collection Antiseptic preparations containing iodine applied to the anal area Ingesting substances which can irritate the GI tract causing bleeding such as aspirin, non-steroidal anti-inflammatory drugs, corticosteroids, indomethacin, phenybutazone, reserpine, anticoagulants, antimetabolites, chemotherapy drugs, excess alcohol, etc.
48 Hemoccult Cards for Fecal Occult Blood Now lets see how much you have learned about the Hemoccult test. In the following slides, you will be asked questions about collecting or performing the Hemoccult test. Try to answer each question with what you have learned and then click under the question to get the answer and check your memory. Lets see how well you do! Review Questions
49 1. The Hemoccult cards can be used for any type of body fluid or type. False - they should be used for fecal samples only! 2. A patient result is valid if the positive control does not turn blue. False - if the positive control does not turn blue the card is not usable. 3. A positive Hemoccult test does not mean that a patient has colon cancer. True - a positive must be followed up by more definitive tests in order to make a cancer diagnosis. True or False answers To see the answer, mouse click under the question. Review Questions Hemoccult Cards for Fecal Occult Blood
50 Review Questions True or False answers To see the answer, mouse click under the question. 4. A negative result means that no occult blood is in the fecal sample. True 5. Collecting samples over three days is optimal for detecting blood. True 6. The positive and negative control must be tested and read correctly in order for the patient result to be considered accurate. True Hemoccult Cards for Fecal Occult Blood
51 Review Questions True or False answers To see the answer, mouse click under the question 7. Hemoccult developer must be refrigerated. False 8. If the back of the Hemoccult card is opened prior to testing, it should not be used. True 9. Gastric samples should be tested with Gastroccult cards. True Hemoccult Cards for Fecal Occult Blood
52 Review Questions True or False answers To see the answer, mouse click under the question 10. After the developer is dropped on the sample, you can read the result at any time. False - the result must be read within 60 seconds while watching the card. Do not walk away as the blue color may fade quickly. 11. Expired cards may be used if no others are available. False - expired cards should never be used. 12. Once the fecal sample is applied to the card it can be mailed at any time - there is no time limit. False - cards must be developed within 14 days after application. Hemoccult Cards for Fecal Occult Blood
53 Please take a minute now to find the Hemoccult Training Checklist. A copy can be found in the Waived Testing Procedure Manual. This training checklist lists all the important facts that you should know about the Hemoccult test. When you finish this presentation, please read the list and check that you understand all the information included. When you are finished, print your name, date the list, sign where requested and give this list to the manager or coordinator at your site to keep for JCAHO inspections. Hemoccult Cards for Fecal Occult Blood Hemoccult Training Checklist
54 HemoccultTraining checklist with documentation on back. Hemoccult Cards for Fecal Occult Blood
55 Please refer any questions or problems to: Geri Augustine BS MT(ASCP) CLS(NCA) Technical Specialist - Near Patient Testing. Loyola Medical Laboratories Loyola University Medical Center (708) 216 -8044 or x68044 To end show, close the box with the X in the upper right hand corner. This concludes the Hemoccult test training presentation.