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Policy # MI/SER/v48
Microbiology Department
116
Policy & Procedure Manual
Section: Serology Manual
Issued by: LABORATORY MANAGER
Original Date: March 14, 2001
Approved by: Laboratory Director
Revision Date: October 29, 2015
Annual Review October 15, 2015
SEROLOGY MANUAL
TABLE OF CONTENTS
Immucor Capture-CMV ........................................................................................................................ 3
Architect System for HBsAb, HBcAb-IgM, HBcAbTotal, HAV-IgM, HCVAb, CMV IgG, CMV
IgM, CMV Avidity, HIV-1/2, HTLV I/II, EBV VCA IgG, EBV EBNA-1 IgG, Rubella IgG,
Syphilis TP Ab, HBsAg Qualitative and HBsAg Qualitative Confirmatory .................................... 6
Daily Procedure .................................................................................................................................. 8
To add new control lot in LIS ............................................................................................................ 9
To enter NEW Control Lot# onto Architect: ..................................................................................... 9
To order Controls for specific lot #: ................................................................................................ 10
To order reagent Calibration ............................................................................................................ 10
Verify QC results in LIS .................................................................................................................. 11
To manually add an order ................................................................................................................ 12
Cut-off Values.................................................................................................................................. 14
Reflex testing and resulting ............................................................................................................. 15
HBsAg Qualitative Confirmatory: ................................................................................................... 1
To order HBsAg Qulitative Confirmatory Calibration ...................................................................... 1
To order HBsAg Qualitative confirmatory Control: .......................................................................... 1
To order HBsAg Qualitative Confirmatory test for patient ............................................................... 2
STAT Testing: .................................................................................................................................... 3
For needle stick incident: ................................................................................................................... 3
For Case room patients that have no previous prenatal testing done: ................................................ 3
Donor/Recipient Serology reporting: ................................................................................................. 5
Trillium Gift of Life Network Procedure ............................................................................................ 8
Weekly Duties ..................................................................................................................................... 9
Trouble shooting .............................................................................................................................. 11
Quality Control ................................................................................................................................ 15
George Washington Serology Study................................................................................................... 17
Specimen Management for George Washington samples ............................................................ 20
Procedure .......................................................................................................................................... 21
CMV Avidity Trouble Shooting ..................................................................................................... 24
GW CMV Avidity algorithm: ......................................................................................................... 25
GW Hepatitis C antibodies Algorithm: ......................................................................................... 26
CMV Avidity result reporting: ....................................................................................................... 27
Anit-HCV result reporting for Architect: ..................................................................................... 28
HCV Ab EIA Serology for George Washington ............................................................................... 30
Hepatitis Virus Serology ....................................................................................................................... 41
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Aspergillus Galactomannan Antigen Detection Assay ...................................................................... 43
Infectious Mononucleosis Heterophile Antibodies .............................................................................. 55
Pneumocystis jiroveci (previously known as P. carinii) DFA TEST ................................................ 57
Syphilis Screening ................................................................................................................................ 61
Varicella-Zoster Virus IgG ................................................................................................................. 64
Appendix I - Serology Test Schedule ................................................................................................... 70
Appendix II - List of Tests Referred Out to Other Laboratories ...................................................... 71
Appendix III - Daily Work-Up for Architect Bench ........................................................................... 74
Appendix IV - Entering and Verifying Serology Refer-Out Results.................................................. 76
Refer-out Reporting Bench Workflow and Notes: ....................................................................... 76
Entering and Verifying Verbal Reports ........................................................................................ 77
Entering and Verifying Serology Refer-Out Results Procedure ................................................. 78
Appendix V - Autoverification Process................................................................................................ 82
Appendix VI - Shipment of Samples to HSC....................................................................................... 85
Appendix VII - Looking Up Previous Hepatitis Results in EPR ..................................................... 86
Appendix VIII - Printing of Pending List............................................................................................ 87
Appendix IX – Donor Serology and Molecular Tests List.................................................................. 88
Appendix X – Movement Throughout Containment Zones ............................................................... 89
Record of Edited Revisions ................................................................................................................. 91
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Immucor Capture-CMV
1. Introduction
The Immucor Capture-CMV is an in vitro qualitative solid phase red cell adherence test system
for the detection of antibodies (IgG plus IgM) to Cytomegalovirus (CMV) in human serum or
plasma. Capture-CMV is intended to be used in screening of donors or patients for serological
evidence of previous infection by CMV.
2. Specimen Collection
Serum or plasma can be separated from red cells and stored at 1-10oC for up to 1 week,
or frozen at -20oC freezer. Sample should not be repeatedly frozen and thawed.
Gel separation tube for serum collection is not recommended.
3. Procedure
a. Reagent preparation:
i. Working Wash solution: Add 4mL pHix to 400 mL of Isotonic Saline. Check the
pH using litmus paper with range of 6.0-8.0-pH should be 6.5-7.2. Good for 30
days when stored at room temperature. Mark ‘ Date Made’ on Working Wash
Solution bottle.
ii. Capture-CMV Microtitration wells: Rigid U-bottom microtitration well coated
with glycine-extracted and purified CMV antigen obtained from CMV 169
grown in human foreskin fibroblast cells. The wells are enclosed in a foil pouch
to which a desiccant and moisture indicator has been added. Store the pouch at 130oC. Remove the number of strips needed and carefully re-seal pouch to prevent
the uptake of moisture. Once pouch is opened, the microtitration wells should be
used within 2 weeks if the moisture indicator stays blue. The Microtitration wells
should not be used if the moisture indicator turns pink. Microtitration wells
removed from the pouch should be used within one (1) hour.
iii. Capture-CMV Positive Control Serum(weak), store at 1-10oC.
iv. Capture-CMV Negative Control serum, store at 1-10oC.
v. Capture LISS: a low ionic strength solution containing Glycine-bromcresol
purple dye and sodium azide. Store at 1-10oC.
vi. Capture-CMV indicator Red-Cells, store at 1-10oC.
b. Assay Method:
1. Bring reagents to room temperature.
2. Remove Capture-CMV Microtitration wells from the pouch.
3. Add 2 drops (100 uL ± 10 uL) of Capture-LISS to all test wells. The color will
change from purple to blue once the control/specimen has been added.
4. Add 1 drop (50 uL ± 5 uL) of Capture-CMV Positive Control Serum (weak) to a
designated well.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
5. Add 1 drop (50 uL ± 5 uL) of Capture-CMV Negative Control Serum to a
designated well.
6. Add 1 drop (50 uL ± 5 uL) of the first specimen to the third well, continue
adding to the designated wells for the rest of the specimens.
7. Incubate at 18-30oC for a minimum of 5 minutes, but no more than
30 minutes.
8. Manually wash strips, gently 6 times, with Working Wash Solution.
9. Re-suspend Capture-CMV indicator Red-Cells by gently inverting the vial.
Immediately add 1 drop (50 uL ± 5 uL) of Capture-CMV indicator Red-Cells to
each well.
10. Load strips into ImmuSpin centrifuge. Centrifuge the microtitration wells using
program 1 (350 RCF) for 2 minute. Then centrifuge again using program 2 (650
RCF) for 1 minute. Remove strip(s) from centrifuge immediately, and leave on a
flat surface.
11. Place the microtitration wells on an illuminated surface and for adherence or the
absence of indicator cells.
4. Interpretation of Result
Negative test: A button of the Capture-CMV indicator Red-Cells at the bottom of the test well
with no area of adherence indicates the test sample has no detection CMV antibody and the
person has not yet been infected with CMV and is presumed to be susceptible to primary
infection.
Positive test: Adherence of Capture-CMV indicator Red-Cells to part or the entire reaction
surface indicates a person with previous current infection and who is presumed to be at risk of
transmitting CMV infection but who is not necessarily currently contagious.
Indeterminate test: Undefined/rough edged button of Capture-CMV indicator Red-Cells at the
bottom of the test well. Appearance of some adherence of the Capture-CMV Indicator RedCells as well as a button formation. Indeterminate CMV antibody status.
All results are confirmed by another technologist before reporting.
Notes for Donor Resulting:
Live donor samples from Sick Children’s Hospital testing positive by the Immucor Capture
method will be run on the architect for CMV IgG (8CMS) and CMV IgM (10CMM).
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
5. Assay Validation
Test is valid when:
Weak Positive Control shows adherence of Indicator Cells over part or all of reaction surface.
Negative Control shows a button of Red Indicator cells at the bottom of the well with no area of
adherence
6. Quality Control
One Positive Control and one Negative Control must be included with each run.
External controls are tested the first week of each month.
Run ViroTorch/ ViroTorch-M.as Positive external control and Viroclear as Negative External
Control.
CAP provides external control testing.
All QC is checked by senior technologist.
7.
Reference
Package insert from Capture-CMV kit by Immucor Gamma, Version 9/10
Capture Guide by Immucor Gamma, Version 200, Revision 7/05
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Policy # MI/SER/v48
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Architect System for HBsAb, HBcAb-IgM, HBcAbTotal, HAV-IgM, HCVAb, CMV
IgG, CMV IgM, CMV Avidity, HIV-1/2, HTLV I/II, EBV VCA IgG, EBV EBNA-1 IgG,
Rubella IgG, Syphilis TP Ab, HBsAg Qualitative and HBsAg Qualitative Confirmatory
I.
Introduction
The Abbott Architect System is a fully automated random access analyser that utilizes a
chemiluminescent microparticle immunoassay (CMIA) technology with flexible assay protocols,
refer to as Chemflex®. At first, sample containing either Antigen or Antibody is combined with
Antigen or Antibody coated paramagnet particles. Antigen or Antibody present in the sample binds
to the Antibody or Antigen coated paramagnet particles. After washing, acridinium-labeled
Antigen conjugate or Antibody conjugate is added in the second step. Following another wash
cycler, Pre-trigger and Trigger Solutions are added to the reaction mixture. The resulting
chemiluminescent reaction is measured as relative light unit (RLU).A direct relationship exists
between the amount of Antigen or Antibody in the sample and the RLUs detected by the Architect
System optics.
Assays run in Architect are as follows:
Anti-HBs, Anti-HBc II, Anti-HBc IgM, Anti-HCV, HIV Ag/Ab Combo, HAVAb-IgG, HAVAbIgM, rHTLV I/II , CMV IgG, CMV IgG Avidity, CMV IgM, EBV VCA IgG, EBV EBNA-1 IgG,
Rubella IgG, Syphilis TP, HBsAg Qualitaitve II, and HBsAg Qualitative confirmatory.
Note: HAVM, HBCM and CMV Avidity are NOT validated on iSR53877 (module 2).
II.
Specimen Type, Preparation and Storage
Specimen type
Specimen collected (5mL for adult and 1mL for neonates) in serum separator tube or potassium
EDTA tubes may be tested on Architect. For other specimen type refer to each assay package
insert.
Proficiency testing specimens must follow the accompanying guidelines for processing and
storage.
Specimen preparation




Follow the tube manufacture’s processing instructions for serum and plasma collection tubes.
Gravity separation is not sufficient for specimen preparation.
Previously frozen specimens must be thaw thoroughly.
Mix thawed specimens by low speed vortexing or by inverting 10 times. Visually inspect the
specimens. If layering or stratification is observed, continue mixing until specimens are visibly
homogeneous.
To ensure consistency in results, specimens must be transferred to a centrifuge tube and
centrifuged at ≥10,000 RCF (Relative Centrifugal Force) for 10 minutes before testing if
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Policy & Procedure Manual
Section: Serology Manual

o They contain fibrin, red blood cells, or other particulate matter,
o They require repeat testing, or
o They were frozen and thawed
Transfer clarified specimen to a sample cup or secondary tube for testing.
Centrifuged specimens with a lipid layer on the top must be transferred to a sample cup or
secondary tube. Care must be taken to transfer only the clarified specimen without the lipemic
material.
Specimen storage
Specimens may be stored on or off the clot, red blood cells, or separator gel for up to 14 days
refrigerated at 2-8 oC.
If testing will be delayed more than 14 days, remove serum or plasma from the clot, red blood
cells, or separator gel. Store serum or plasma at frozen temperature (-10 oC or colder)
III.
Reagents and bulk solutions
REAGENT KIT, CONTROL KIT, CALIBRATOR KIT: Instructions must be carefully followed in
each assay package insert. Stored at 4 oC.
CONCENTRATED WASH BUFFER: Must be diluted prior to use. Contains 1.5M phosphate
buffered saline with antimicrobial agents. Stored at room temperature.
PRE-TRIGGER SOLUTION: Contains 1.32 %( w/v) hydrogen peroxide. Once opened, placed on
board the system no longer than 28 days, then discards. Stored at 4 oC.
TRIGGER SOLUTION: Contains 0.35N sodium hydroxide. Once opened, placed on board the
systems no longer than 28days, then discard. Stored at room temperature.
PROBE CONDITIONING SOLUTION: Contains recalcified human plasma; has infection risk.
Preservatives: Antimicrobial Agent and ProClin 300. Stored at 4 oC.
IV.
Equipment and Materials
 ARCHITECT i System
 ARCHITECT i System Assay CD-ROM
 ARCHITECT i reaction vessels
 ARCHITECT i sample cups
 ARCHITECT i septum
 ARCHITECT i replacement caps
 Pipettes
For information on materials required for maintenance procedures, refer to the ARCHITECT
System Operation Manual.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
V.
Daily Procedure
At snapshot screen:
1. Touch ‘Log Off’ to log-on with your initials
2. Touch SCC (system control center) and RSH (Robotic sample handler) and ‘Pause’. The
status will change from ‘Running’ to ‘Ready’.
(The opening of Reagent Carousel lid and turning of the carousel can only be done when
Architect is in ‘Ready’ mode.)
3. Check ‘Supplies’ to ensure adequate consumables on board. A yellow caution symbol
will appear when reagents or reaction cells are less than 20%. This consumable should be
loaded immediately or the next time the machine is on pause.
4. View Reagent Load List to determine which kits need to be loaded. You may print the
Load list if needed.
(Touch Reagent Icon on Snapshot, ‘View All’, Touch ‘ASSAY’ to group same reagents
together)
5. Performing daily maintenance:
a. Touch ‘System’ and ‘Maintenance’ Highlight ‘6041 Daily Maintenance’ ‘Perform’ at
the bottom of the screen
b. Fill WZ probe maintenance bottle with 25-30 ml of 0.5% Hypochloride (Javex) ( 2.0 ml
of Javex with 400 ml of tap water, is good for one month)
c. Place a clean septum on probe conditioning solution bottle if a new bottle is opened
d. Follow the online instructions. Maintenance will take approximately 21 minutes.
e. When completed, empty 0.5% Hypochloride bottle and rinse it with tap water.
6. Load reagents :
a. Take out adequate reagents according to the Reagent Load List replacing cap with a
clean septum.
! Invert the microparticle bottle (pink label) 30 times for the first time loading on
the ARCHITECT system
! If the microparticles do not resuspend, DO NOT USE. Contact senior/charge
technologist
b. On the reagent package, write down the SN# from the MICROPARTICLE (pink) bottle
c. Load the reagent bottles onto architect according to the color of the labels and the colour
on the rings.
d. All Anti-HCV Reagents already on board should be inverted 3 times.
7. Check reagent controls to ensure there is adequate volume in each sample cup to run QC.
(If the level reaches the first mark, then it is still good for one more run).
a. Change each sample cup when volume is too low, and fill up to about 1/3 full. Do NOT
overfill. Label the top with name of each control; write down lot number, expiration
date, and date-in-use on the side.
b. If new controls are used, updates in Architect and LIS must be done at the same time.
Architect must be paused to change control lots.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
To add new control lot in LIS:
a. Log in to Soft QC
b. Press “F1” on the keyboard to exit the EMAILs
c. Select #4-Maintenance
i) Select “Add new level”
 Enter old lot # with N/P/P1/P2 or P3 at the end;
 Enter New lot # with N/P/P1/P2 or P3 at the end;
 Press 'F12' 3 times ;
 Press 'Y'
 Enter expiration date;
 Repeat with each level;
 Once all levels are added, press 'F1' to exit.
ii) Select “Deactivate old Lot”:
 Enter old lot# with N/P/P1/P2/ or P3 at the end;
 Press 'F12' twice;
 Press 'Y';
 Press 'F1' to exit
 Repeat with each level;
 Once all levels are deactivated, press 'F1' to exit
iii) Activate new lot:
 Enter new lot# with N/P/P1/P2 or P3 at the end;
 Press 'F12' twice;
 Press 'Y';
 Press 'F1' to exit
 Repeat with each level;
 Once all levels are activated, press 'F1' to exit.
To enter NEW Control Lot# onto Architect:
a. Change control lot number for the single analyte
 Log on as ‘ADMIN’, pass word’ ADM’
 Architect must be in pause mode.
 Touch ‘System’, ‘Configuration’, ‘QC Cal Setting’
 In the QC-categories panel, ‘QC single analyte’ is highlighted as default.
 In the Assays panel, choose the assay needs to be updated e.g. HBsAg.
 Select ‘Configure’.
 A new screen will come up showing lot #, touch box with bar:
 Select ‘New lot-copy data’ from the drop down menu
 Highlight lot #, enter new lot #, Highlight exp date, enter new exp date.
 Check ‘Default’, then ‘Done’.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
b. Change control lot number for the multiconstituent controls :CMV avidity and
HBsAgQ2+(HBsAg confirmatory)
i.
Log on as ‘ADMIN’, pass word’ ADM’
ii.
Architect must be in pause mode.
iii. Touch ‘System’, ‘Configuration’, ‘QC Cal Setting’
iv.
In the QC-categories panel , select QC-Multiconstituents
v.
In the Assays panel, choose the assay needs to be updated: CMV Avidity
or HBsAgQ2+.
vi.
Select ‘Configure’.
vii.
Press Ctrl+Alt+Print Scrn, configuration summary sheet will be printed
viii. Touch box with bar
beside Level, select and print out each level
configuration summary sheet by pressing Ctrl+Alt+Print Scrn
ix. Touch box with bar
beside lot number .
x. Select ‘New Lot’ from the drop down menu
xi. Type now lot# and expiration date
xii. Highlight the 1st test in the assay panel
xiii. Touch ‘Define data’
xiv. Type the data in the proper place according to the configuration summary
sheet for each level. Touch “Add Level”. Then proceed to enter Level 2.
xv. Touch ‘Done’
xvi. Repeat from xiii to xvi for all the assays
xvii. Review the screen against the print out summary to make sure everything
is correct
xviii. Check ‘Default’.
xix. Touch ‘Done’.
8. Load controls
1) Bar-coded controls: Load bar-coded controls showing barcode directly onto architect
2) Non bar-coded controls:
To order Controls for specific lot #:
a. Touch ‘Order’, ‘ Control Order’. Select ‘Single Analyte’
b. Scan in Carrier #, type in position #.
c. Select the assay, e.g. ‘HBsAg auto’
d. Select the control (P1, P2, Negative)
e. Touch ‘Add order’.
f. Do this for EACH positive and negative control.
To order reagent Calibration (for reagent with new lot number):
a. Touch ‘Order’ from snapshot screen, select ‘Calibration’.
b. Scan in Carrier #, type in position #.
c. Select the assay, e.g. ‘HBsAg auto’
d. Touch ‘Assay option…’ to check the in-use calibrator lot number
1) If the in-use calibrator has new lot number
 Highlight lot#
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Section: Serology Manual
 Enter new calibrator lot#
 Enter new calibrator expiration date
 Touch ‘Done’ button; Touch ‘Add Order’
2) If the in-use calibrator has same lot number
 Touch ‘Cancel’ button, Touch ‘Add Order’
9. Once controls are finished, the ‘QC-Cal’ will be flashing. Print out the QC results:
 Touch ‘QC-Cal’, select ‘QC result review’
 Touch ‘C/P’ to group same QCs together
 Touch ‘Select All’ Touch ‘Print’
 Touch ‘Unselect All’
 Highlight the assay that have new reagent loaded earlier
 Touch ‘Details’ to find the reagent which SN matches the one on the reagent
package.
 Write down both reagent and control lot numbers, record new reagent control
results into Architect Lot-Cal-QC chart
10. Check the QC results. If there is no flags appeared on the QC print-out sheets:
 If there is no flags appeared on the QC print-out sheets: Touch ‘Select All’, Touch
‘Release’ to transmit all QC results to LIS
 1-2sd flag:
- Touch ‘QC-Cal’, select ‘Levey-Jennings graph’
- From Assay panel, select the assay which has 2S flag, touch ‘Done’
If the 1-2sd flag is the first time, write ‘1st time’ on the QC print-out beside the
flag.
If the 1-2sd flag is the second time, change the control aliquot and repeat QC
If there are more than one level has 2S flag for the same reagent, check the control
aliquots:
- If the control aliquots are old, change the control aliquots and repeat QC
- If the control aliquots are new, recalibrate the reagent and repeat the whole
set of the controls
 1-3sd flag:
If the control aliquots are old, change the control aliquots and repeat QC
If the control aliquots are new, recalibrate the reagent and repeat the whole set of
the controls
11. Verify QC results in LIS
- In ‘Softlab’, select ‘Interfaces’
- Double click ‘Instrument Menu’, Double click the ‘ ARCHI Abbott Architect’
- Press ‘Shift’ and ‘+’ keys together to verify each QC result.
12. Finish Architect daily QC in LIS
- Go to SoftMic, Click Results, Click virology Worklist, Double click Architect
- Click ‘Yes’ in the following window to go to SoftQC.
- Complete designed QC .
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Section: Serology Manual
13. Load patients’ specimen
1) Ensure each label has a “96” extension. A sample cup can be placed inside the
blood tube if serum/plasma level is low or sample comes aliquoted. Once samples
are loaded, the Orange light will light up. Carriers can be unloaded if there is solid
green lights or flashing green/yellow lights. Carriers can NOT be unloaded if there
is solid yellow lights. Stat samples can be loaded in individual carrier’s slots at any
time.
2) To manually add an order:
- Touch ‘Order’, select ‘Patient Order’.
- Scan in Carrier #. type in position #.
- Touch ID field, scan in order#
- Select all the tests required in Assay panel.
- Touch ‘Sample details’.
- Type in ‘Last name’ and ‘First name’.
- Touch ‘Done’, Touch ‘Add Order’
14. Update supplies
A yellow caution symbol ! will appear when reagents or reaction cells are less than 20%
under the appropriate module.
1) Wash buffer:
- 2 bulk boxes of 10L concentrated wash buffer are on board ALL THE TIME
- Working buffer will automatically be filled by ARM system.
2) Trigger/Pre-trigger solution: Change at the beginning of your shift if less than 20%. If the
caution symbol appears midway through testing, change the solution the next time the
architect is paused.
3) Add reaction cells:
i. Monitor the supplies caution symbol, however, ensure there are enough RVs in the
hopper so the red sensor light is always on.
1. At snapshot screen, touch ‘Supplies’
2. Touch ‘Supply status’
3. Select ‘module 1’ or ‘module 2’
4. Touch ‘update supplies’
5. Select ‘RVs added 500/1000’ or enter estimated number (1 bag has 500
RVs)
6. Touch ‘Done’ and ‘Exit’ to go back snapshot screen
! Do NOT overfill RVs to prevent RV jam
4) Liquid waste is drained directly from Architect into the floor drain.
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Section: Serology Manual
15. Once all tests are finished, the ‘Result’ field will be flashing.
a. Touch ‘Result’, Select ‘Result review’,
b. Highlight the results to be printed.
c. Touch ‘Print’, Select ‘Result LIS Report’ and once printed, release highlighted
results. (For HBsAg confirmatory result, select ‘Sample Report’)
16. Underline Positive result or anything requiring reflex testing including: HBsAg Qualitative,
Positive HCA, Positive HBcAb, Positive HBcAb IgM, Positive HIV, Positive VD,
Negative and low Positive Rubella, low Positive CMS, follow reporting chart to report each
result
- Initial anything you have verified manually
- Indicate where reflex testing is being done
- Highlight and mark all NEW Hep B Ag or Hep C ab results
Leave completed testing printouts on the senior bench for revision.
17. Architect must be on ‘running’ mode overnight, so that all the solutions will be flushed
regularly
18. Log the quantity of the buffer bottles used the day before onto Architect consumable log
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Policy # MI/SER/v48
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
VI.
Cut-off Values
Assay
LIS code
HBsAg
(Qualitative)
HBsAb
HbcAbII
HbcII IgM
8HAGX
Equivocal/
Gray Zone
Neg
Pos
<1.00 S/CO
≥ 1.00 S/CO
Refer to reflex testing
details
8HAB
8HBC
8HBCM
<10.00 mIU/ml
<1.00 S/CO
<1.00 S/CO
≥ 10.00 IU/L
≥ 1.00 S/CO
≥ 1.00 S/CO
1.00-5.00 S/CO
HCV Ab
8HCA
<1.00 S/CO
≥1.00 S/CO
Refer to reflex testing
details
HIV 1&2
8TSC
<1.00 S/CO
HAV IgM
8HAVG
<0.08 S/CO
≥1.00 S/CO*
>1.20 S/CO
HAV IgG
8HAV
<1.00 S/CO
≥1.00 S/CO
EBV VCA IgG
8EBVG
<0.75 S/CO
> or = 1.00 S/CO
EBV EBNA-1 IgG
8EBNA
<0.5 S/CO
> or = 1.00 S/CO
Rubella IgG
8RUB
0.00-4.9 IU/mL
CMV IgGR
8CMS
<6.0 AU/mL
CMV IgM
CMV Avidity
SyphilisTP Ab
HTLV I/II
HBsAg
Confirmatory
10CMM
10CMA
8VD
8HTLA
<10 Index
<50%(Low avidity)
<1.00 S/CO
<1.00 S/CO
<50% (Not
confirmed)
8CON
≥10.00 IU/mL
10.0-15.0 IU/mL (Low
Level)
≥6.0 AU/mL
6.00-15.00 AU/mL(Low
Level)
≥1.00 Index
>50%(High Avidity)
≥1.00 S/CO
≥1.00 S/CO*
Reflex Range
0.08-1.20 S/CO
(Gray Zone)
0.75-1.00 S/CO
(Equivocal)
0.5-1.00 S/CO
(Equivocal)
5.00-9.90 IU/mL
(Gray Zone)
0.00-9.9 IU/mL
>50% (Confirmed)
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Policy # MI/SER/v48
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Result Reporting
Result reporting includes auto verification by LIS and manually verification by operator.
For auto verification process, refer to auto verification process.
For manually verification, refer to Reflex testing and resulting
VII.
Reflex testing and resulting:
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Policy # MI/SER/v48
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
8HAGX (HBsAg Qualitative)
8HAGX
Patient
History
8CHK
8HBC
8HBC2
Positive
(>5.0 S/CO)
Not Done (Hag+)
8CON
both positive
(≥1.0 S/CO)
Confirmed
≥50%
one Positive
(≥1.0 S/CO)
Positive
(>1.00 S/O)
New
Positive
(>1.00S/CO
Enter "New
Positive" and
verify
Positive
1.0 ≤HBC<5.0
S/CO
one Negative
(<1.0S/CO)
Both Negative
(<1.0S/CO)
Negative
(<1.0S/C)
POSITIVE
(>1.00 S/O)
Previous
Positive
Enter
"Previous
+ve" and
verify
N/A
Comment
1) Report 8HBC and 8HBC2 as per HBC
reporting table
2) Do not verify 8HAGX result
3) Order 8CON.
4) Result as “.Conf” (ensure there is a dot
before) and verify
5) Highlight 8HAGX new positive on print
out and give to Senior for CD
Yes
Not
Confirmed
<50%
1) Report 8HBC and 8HBC2 as per HBC
reporting table
2) Do not verify 8HAGX result
3) Order 8CON.
4) Result as “.NotConf” (ensure there is a
dot before) and verify
5) Consult with Senior or Charge tech.
N/A
N/A
N/A
1) Verify Negative 8HAGX result in LIS
2) Report 8HBC as "Not done Hag+" and
verify
3) Delete HBcII in pending list on
Architect
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Policy # MI/SER/v48
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
8HBC ordered only or HBsAg is ‘Negative’
8HBC
8HBC2
Positive
(>5.0 S/CO)
Result ‘Not Need’ and verify
both positive
(≥1.0 S/CO)
one Positive
(≥1.0 S/CO)
Positive
1.0 ≤HBC<5.0 S/CO
one Negative
(<1.0S/CO)
Both Negative
(<1.0S/CO)
Comment
1) Report 8HBC as "Positive" and verify
1)
2)
3)
4)
5)
6)
1)
2)
3)
4)
5)
6)
7)
1)
2)
3)
4)
5)
6)
There are 2 8HBC reflexes in the pending list on Architect
Do not release HBC result before both 8HBC2 complete
Print all 3 8HBC results
Release all 3 positive results
Take off keypad and report 8HBC2 as "Positive" in LIS and
verify
Report 8HBC as "Positive" and verify
There are 2 8HBC reflexes in the pending list on Architect
Do not release HBC result before both 8HBC2 complete
Print all 3 8HBC results
Release both two positive results
Take off keypad and report 8HBC2 as "Positive" in LIS and
verify
Report 8HBC as "Positive" and verify
Release negative 8HBC2 from Architect
There are 2 8HBC reflexes in the pending list on Architect
Do not release HBC result before both 8HBC2 complete
Print all 3 8HBC results
Release both negative results FIRST, 8HBC will be reported
as negative and auto verified
Then release positive result
Take off keypad and report 8HBC2 as "Negative" in LIS and
verify
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Policy # MI/SER/v48
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
HCA
8HCA
Patient History
8HCA2
>10.00 S/CO
Comment
1)
2)
3)
1)
2)
New Positive
Positive
(>10.00 S/CO)
<10.00 S/CO
Previous Positive
3)
N/A
<10.00 S/CO
1)
2)
3)
4)
1)
2)
New Positive
Positive
1.0 ≤HCA<10.00 S/CO
>10.00 S/CO
Previous Positive
N/A
3)
1)
2)
3)
Result reflex 8HCA2 as "Positive" and verify
Result 8HCA as “Positive”---Do not verify
Highlight new positive HCA on print out and give to senior for CD
Repeat one more 8HCA
If 2 results out of 3 are >10.00S/CO:
i) Result reflex 8HCA2 as “Positive” and verify
ii) Result 8HCA as “Positive”---Do not verify
iii) Highlight new positive HCA on print out and give to senior for CD
If 2 results out of 3 are < 10.00S/CO:
i) Result reflex 8HCA2 as “Positive” and verify
ii) Result 8HCA as “To PHL@MOH+” and verify
iii) Order 9HCA and print out send-out form using “RLRF5, RR13”
iv) Send specimen to PHL for confirmation
1) Result 8HCA as “Positive” and verify
2) Result reflex 8HCA2 as “Prev. conf” and verify
3) Delete reflex order from pending list on Architect
Result reflex 8HCA2 as "Positive" and verify
Result 8HCA as “ To PHL@MOH+” and verify
Order 9HCA and print out send-out form using “RLRF5, RR13”
Send specimen to PHL for confirmation
Repeat one more 8HCA
If 2 results out of 3 are >10.00S/CO:
i) Result reflex 8HCA2 as “Positive” and verify
ii) Result 8HCA as “Positive”---Do not verify
iii) Highlight new positive HCA on print out and give to senior for CD
If 2 results out of 3 are < 10.00S/CO:
i) Result reflex 8HCA2 as “Positive” and verify
ii) Result 8HCA as “To PHL@MOH+” and verify
iii) Order 9HCA and print out send-out form using “RLRF5, RR13”
iv) Send specimen to PHL for confirmation
Result 8HCA as “Positive” and verify
Result reflex 8HCA2 as “Prev. conf” and verify
Delete reflex order from pending list on Architect
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Policy # MI/SER/v48
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
8RUB
8RUB
Negative
0.0-4.9IU/mL
8RUB2
Negative
0.0-4.9 IU/mL
Or
Gray zone
5.00-9.9IU/mL
Negative
0.0-4.9 IU/mL
Or
Gray zone
5.00-9.9IU/mL
Gray zone
5.00-9.9IU/mL
Low Positive
10-15IU/mL
Low Positive
10-15 IU/mL
N/A
Comment
1) Result 8RUB2 as “Negative” and verify
2) Result 8RUB as “Negative” and verify
1) Result 8RUB2 as “Negative” and verify
2) Result 8RUB as “Negative” and verify
1) Repeat one more reflex
2) If 2/3 results are negative or grayzone
i) Result 8RUB2 as “Negative” and verify
ii) Result 8RUB as “Negative” and verify
3) If 2/3 results are low positive
i) Result 8RUB2 as “Low Positive” and verify
ii) Result 8RUB as “Low Positive” and verify
1) 8RUB will be auto verified
2) Manually change 8RUB result to “Positive@low level” and verify
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Policy # MI/SER/v48
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
8CMS
8CMS
Comment
6-15Au/mL
1) 8CMS will be auto verified
2) Manually change 8CMS result to “Positive@low level” and
verify
8TSC
8TSC
≥1.00S/CO
Comment
1) Result 8TSC as “To PHL@MOH+” and verify
2) Order 9TSC and print send -out form using “RL10H,
RR10”
3) Send specimen to PHL
8HTLA
8HTLA
≥1.00S/CO
Comment
1) Result 8HTLA as “To PHL@MOH+” and verify
2) Order 9HTL and print send -out form using “RL10H,
RR10”
3) Send specimen to PHL
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Policy # MI/SER/v48
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
8VD
8VD
≥1.00S/CO
Comment
1) Result 8VD as “To PHL@MOH+” and verify
2) Order 9VD and print send -out form using “RLRF5,
RR13”
3) Send specimen to PHL
8HAV
8HAV
>1.20S/CO
Comment
1) Result 8HAV as “POSITIVE” and verify
2) Call ward regarding positive HAV IgM result
3) Check report and fax the report (RL15, RL10) to MOH
:416-392-0047 on regular hours(8:30-16:30)
4) phone MOH on after-hours(416-392-CITY (2489)
5) Check the link of Reportable Diseases to the Medical
Officer of Health
8HBCM
8HBCM
≥1.00S/CO
Comment
1) Verify 8HBCM result in LIS
2) No reflex needed
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Policy # MI/SER/v48
Page 1 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
VIII.
HBsAg Qualitative Confirmatory:
! Only order 8CON in LIS AFTER the confirmatory results are completed and released
Set Architect in Ready Mode, and load the HBsAg confirmatory reagents.
To order HBsAg Qulitative Confirmatory Calibration:
1. At snapshot screen, touch ‘Order’, Select ‘Calibration order’.
2. Scan in Carrier #, type in position #.
3. In assays panel, select ‘HBsAg Q2 C2’.
4. Touch ‘Assay option…’ to check the calibrator lot number
1. If the in-use calibrator has new lot number
 Highlight lot#
 Enter new calibrator lot#
 Enter new calibrator expiration date
 Touch ‘Done’ button;
 Touch ‘Add Order’
2. If the in-use calibrator has same lot number
 Touch ‘Cancel’ button
 Touch ‘Add Order’
a. Load a carrier with 2 sample cups
b. Add Cal1 to position 1 & add Cal 2 to position 2.
! ALWAYS RUN CONFIRMATORY CONTROL BEFORE SPECIMEN
To order HBsAg Qualitative confirmatory Control:
(Only run HBsAg Qualitaitve II Positive Control):
1. At snapshot screen, touch ‘Order’, Touch ‘Control Order’, Select ‘Multiconstiuent’
2. Touch box with bars
beside ‘Control:’, highlight HBsAgQ2+
3. In the ‘Panel:’ highlight HBsAgQ2Pa
4. Touch ‘Assay options…’ to check the lot number of control
5. If control lot number changes, follow instruction of Change control lot number for the
multicoustituent controls
6. Touch ‘Add Order’
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Policy # MI/SER/v48
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
! Load Control first (Do not show barcode), then patient’s sample
To order HBsAg Qualitative Confirmatory test for patient:
1. At snapshot screen, touch ‘Order’, Touch ‘Patient Order’.
2. Scan in Carrier #., Type in position #
3. At SID, Scan in specimen SID#
4. In ‘Panel’, highlight ‘HBsAgQ2Pa’- HBsAg Q2% N, HBsAg Q2 C1 and HBsAg Q2 C2 will
be highlighted.
5. Touch ‘Sample Details’ and type in patient’s last name and first name,
6. Touch ‘Done’. Touch ‘Add order’.
!Record How Many Tests Left on the Reagent Bottle
To Pint HBsAg Qualitative Confirmatory test
1) Highlight all three assays:HBsAgQ2C1, HBsAgQ2C2, HBsAgQ2%N
2) Touch ‘Print’
3) Select ‘Sample Report’
4) Touch ‘Done’
Interpretation of Results
HBsAgQ2 C2
(S/CO)
UNDILUTED
HBsAgQ2 %N
HBsAg Qualitative
Confirmatory Interpretation
LIS
<0.7 Nonreactive
N/A
HBsAg : Negative
8CON: Not Confirmed
Verify 8CON
<10.00
<50%
HBsAg: Negative
8CON: Not Confirmed
Verify 8CON
≥0.7 Reactive
≥50%
confirmed positive for HBsAg
≥10.00 Reactive
<50%
*Manually dilute 1:500 and
Repeat HBsAg Confirmatory
Testing
.
.
.
8CON: CONF POS
Verify 8CON
*Dilute sample 1:20 first: 25uL patient sample + 475uL Architect HBsAg QII Confirmatory
Manual Diluent with this use 20uL (1:20) + 480uL of Architect HBsAg QII Confirmatory Manual
Diluent for final 1:500 dilution
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Policy # MI/SER/v48
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
IX.
STAT Testing:
!!! Turn Around Time for STAT Testing is 2-hours
For needle stick incident:
1) Source Blood: 8HAGX, 8HCA, 8TSC should always be ordered – tested in house
2) Staff Blood: 8HAB, 8HCA should always be tested - tested in house
Staff HIV Ag/Ab is sent out to PHL for testing.
3) In order entry, make sure in the ‘Reported to ’ is the respective occupational health
department:
 OHS-MSH occupational health
4) All results must be informed to occupational health department by phoned or email
 MSH needle stick results: email results to Occ. Health Clinical Nurses
(ohcn@mtsinai.on.ca)
5) Follow the Architect SOPs regarding any reactive results.
 For regular hours (Monday to Friday from 7:45 to 16:00), contact occupational health
department to find out patient’s history regarding any reactive results.
 For after hours (Monday to Friday from 16:00 to7:00), email microbiologist-on-call
with result value, patient’s information, and name of attending physician.
6) All sera are stored in 10 years storage boxes.
For Case room patients that have no previous prenatal testing done:
Case Room Laboratory Contact Information
1) Do all the tests in house. If HIV requested, also order 9HIV and send out unopened specimen
or minimum 0.5ml serum to PHL for HIV confirmation testing.
2) All results must be phoned to the ward.
3) Follow the Architect SOPs regarding any reactive result.
 Microbiologist on-call must be informed with all reactive syphilis S/CO values.
 For after hours (Monday to Friday from 16:00 to7:00), any reactive HIV screening
result must be emailed to microbiologist-on-call with result value, patient’s information
and name of attending physician.
4) All sera are stored in 10 years storage boxes
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Policy # MI/SER/v48
Page 4 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
X.
Transplant Donor/Recipient Serology Testing
1. STAT serology testing may include the following tests:
Test Name
Hep B Surface
Antigen(Donor
Screening Only)
Hep B surface Antibody
Hep B Core Antibody
LIS code
8HAGX
Hep C Antibody
8HCA
HIV 1&2 Antibody/p24
Antigen
HTLV 1&2 Antibody
8TSC
8HTLA
CMV Total Antibody
Syphilis Screening
8CMSE
8VD
EBV VCA IgG
8EBVG
8HAB
8HBC
Testing Assay
Architect HBsAg Qualitative II,
Device#2G22, Abbott Diagnostics
Architect Anti-HBC II, Device#8L4425, Abbott Diagnostics
Architect Anti-HCV, Device#6C37,
Abbott Diagnostics
Architect HIV Ag/Ab, Device#4J27,
Abbott Diagnostics
Architect HBsAg Qualitative II,
Device#2G22, Abbott Diagnostics
CAPTURE-CMV Kit,Immucor Inc.
Architect Syphilis TP Assay
[donor screen and cadaveric], Device
Identifier 8D06,
Abbott Diagnostics
Architect EBV VCA IgG
assay, Device# 3P65, Abbott
Diagnostics
Donor Serology and Molecular Testing for at MSH Living Donors
Donor Serology and Molecular Testing at Mount Sinai Hospital
2. Testing of cadaveric blood specimens:
 After initial centrifugation, transfer the supernatant to a centrifuge tube and centrifuge
at ≥10,000RCF for 10 minutes prior to testing.
3. NON-STAT test requests e.g. Toxoplasma IgG, VZV IgG, aliquot separate tubes of serum.
 All initial reactive samples (except 8CMSE) MUST be centrifuged at 10,000 rcf for 10
minutes before repeating in duplicate
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Policy # MI/SER/v48
Page 5 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Donor/Recipient Serology reporting:
Test
8HAGX
(S/CO)
Initial Result
Retest In Duplicate
LIS Report
<1.00
(Nonreactive)
N/A
8HAGX:Negati
ve@x1
Both results<1.00
(Nonreactive)
8HAGX:Negati
ve@x1
Living Donor
8HAGX:Positiv
e@x1
≥1.00 (Reactive)
One or both results≥1.00
(Reactive)
Cadaveric
Donor
8HAGX:Positiv
e@x1
<1.00
(Nonreactive)
N/A
Both results<1.0
8HBC (S/CO)
8HBC:Negative
@c1
8HBC:Negative
@c1
8HBC2:Negativ
e
≥1.00 (Reactive)
Negative
Indeterminate
One or Both results≥1.00
(Reactive)
8HBC:Positive
@c1
8HBC2:Positive
N/A
8CMSE:Negativ
e@cm1
N/A
8CMSE:
Indeterminate
@cm1
8CMSE
8EBVG
S/CO
Positive
N/A
8CMSE:Positive
@cm1
<0.75
(Nonreactive)
No Duplicate Retesting
Needed
Add 8EBNA test
8EBVG:
Negative@a1
8EBNA:Based
on EBNA result
0.75≤8EBV<1.00
(Grayzone)
No Duplicate Retesting
Needed
Add 8EBNA test
8EBVG:Equivo
ca@a1
8EBNA:Based
on EBNA result
≥1.00 (Reactive)
N/A
8EBV: Positive
Comment
 Auto-verified
 Verify 8HAGX
 Order 8COM, recorder all values in the comment under
8COM , verify 8COM
 Type ‘Repeatedly Reactive’ in the comment under
8HAGX and verify 8HAGX
 Order 8COM, recorder all HAGX values in the
comment under 8COM , verify 8COM
 FOR ONTARIO LIVING DONOR ONLY, order
9HAG and send specimen to PHL for confirmation.
 Type ‘Repeatedly Reactive’ in the comment under
8HAGX and verify 8HAGX
 Order 8COM, recorder all HAGX values in the
comment under 8COM , verify 8COM
 Auto-verified
 Verify 8HBC &8HBC2
 Record all values in the comment under 8HBC2
 Type ‘Repeatedly Reactive’ in the comment under
8HBC and verify 8HBC
 Record all values in the comment under 8HBC2
 Manually verify
 Manually verify
 For sick kids ONLY
Run CMV IgG (8CMS) and CMV IgM (10CMM) on
Architect
 Manually verify
 Positive 8CMSE result for sick kids needs to run CMV
IgG (8CMS) and CMV IgM (10CMM) on Architect
 Both results are auto-verified
 Both results are auto-verified
 Auto-verified
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Policy # MI/SER/v48
Page 6 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Test
Initial Result
Retest In Duplicate
<1.00
(Nonreactive)
N/A
Both results<1.00
(Nonreactive)
8HCA
(S/CO)
One or Both results≥1.00
(Reactive)
N/A
Both results<1.00
(Nonreactive)
8TSC
(S/CO)
Cadaveric
Donor
8HCA:Positive
@y1
8HCA2:
Positive
8TSC:Negative
@z1
8TSC:Negative
@z1
Living Donor
8TSC:Positive
@z1
≥1.00
(Reactive)
One or both results≥1.00
(Reactive)
<1.00
(Nonreactive)
N/A
Both results<1.00
(Nonreactive)
8HTLA
(S/CO)
8HCA:Negative
@y1
8HCA:Negative
@y1
8HCA2:Negativ
e
Living Donor
8HCA:Posiitve
@y1
8HCA2:Positive
≥1.00
(Reactive)
<1.00
(Nonreactive)
LIS Report
Cadaveric
Donor
8TSC:Positive
@z1
8HTLA:Negativ
e@i1
8HTLA:Negativ
e@i1
Living Donor
8HTLA:Positive
@i1
≥1.00
(Reactive)
One or bother results≥1.00
(Reactive)
Cadaveric
Donor
8HTLA:Positive
@i1
Comment
 Auto-verified
 Verify 8HCA&8HCA2
 Record all values in the comment under 8HCA2
 Type ‘Repeatedly Reactive’ in the comment under
8HCA and verify 8HCA
 Record all values in the comment under 8HCA2 &
verify 8HCA2
 FOR ONTARIO LIVING DONOR ONLY, order
9HCA and send specimen to PHL for confirmation.
 Type ‘Repeated Reactive’ in the comment under
8HCA and verify 8HCA
 Verify 8HCA2
 Record all values in the comment under 8HCA2
 Auto-verified
 Order 8COM, recorder all values in the comment under
8COM
 Verify 8TSC. Result as: “Repeatedly reactive”
 Order 8COM, recorder all values in the comment under
8COM , verify 8COM
 FOR ONTARIO LIVING DONOR ONLY,
Order 9TSC and send specimen to PHL for
confirmation.
 Type ‘Repeated Reactive’ in the comment under 8TSC
and verify 8TSC
 Order 8COM, recorder all values in the comment under
8COM , verify 8COM
 Auto-verified
 Order 8COM, recorder all values in the comment under
8COM, verify 8COM
 Type ‘Repeated Reactive’ in the comment under
8HTLA and verify 8HTLA
 Order 8COM, recorder all values in the comment under
8COM , verify 8COM
 FOR ONTARIO LIVING DONOR ONLY,
Order 9HTLA and send specimen to PHL for
confirmation.
 Type ‘ Repeated Reactive’ in the comment under
8HTLA and verify 8HTLA
 Order 8COM, recorder all values in the comment under
8COM , verify 8COM
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Test
8VD
(S/CO)
Initial Result
Retest In Duplicate
LIS Report
<1.00
(Nonreactive)
N/A
8VD:Negative
@V3
Both results <1.00
(Nonreactive)
8VD:Negative
@V3
Living Donor
8VD:Positive
@V3
≥1.00 (Reactive)
One or Both results: ≥1.00
(Reactive)
Cadaveric
Donor
8VD:Positive
@V3
Comment
 Auto-verified
 Verify 8HVD
 Manually order 8COM, record all values in the
comment under 8COM , verify 8COM
 Type ‘Repeatedly Reactive’ in the comment under
8VD and verify 8VD
 Order 8COM, record all values in the comment under
8COM , verify 8COM
 FOR ONTARIO LIVING DONOR ONLY,
Order 9VD and send specimen to PHL for confirmation
 Type “Repeatedly Reactive’ in the comment under
8VD and verify 8VD.
 Order 8COM, record all values in the comment under
8COM , verify 8COM
Donor Specimen Storage:



Freeze all serum and plasma donor specimens to DONOR storage box.
For specimen storage information refer to Specimen Retention Times manual.
For specimen storage location refer to “Equipment Floor Plan” and “Freezer Room Maps”
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Trillium Gift of Life Network Procedure
Refer to Study Manual: Trillium Gift of Life Network Procedure
Donor Serology and Molecular Testing at Mount Sinai Hospital for TGLN
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
XI.
Weekly Duties
Architect MUST be on Ready mode and log on as ‘ADMIN’ for weekly maintenance and
back-ups!
1. Weekly Maintenance
a. These procedures appear on the maintenance TO DO list automatically:
 6012 Air Filter Cleaning
 6014 Pipettor Probe Cleaning
 6015 WZ Probe cleaning-Manual
b. Select each procedure and touch Perform
! DO NOT FORGET TO REPLACE AND CLEAN THE FILTER UNDER THE
ARCHITECT
c. Follow onboard instruction to finish each procedure
2. Back up weekly-Every Monday
a. Back up files to Architect
 Set architect on the ‘Ready’ mode
 From snapshot screen, touch ‘System’, Touch ‘Utilities’
 Select ‘F4-create back up’
 Touch ‘Done’
b. Back up test results to CD
 From the snapshot screen, touch ‘Results’
 Touch ‘Stored Results’, Touch ‘Select all’, Touch ‘Archive’
 Uncheck ‘delete records after archive before next step’(make sure the
 Touch ‘Done’
 Follow the onboard instruction
 Touch ‘Done’ when test results back-up is finished
 Write the back-up date on the CD cover
c. Back up QC results to CD
 From the snapshot screen, touch ‘QC-Cal’
 Touch ‘Stored QC’, Touch ‘Select all’, Touch ‘Archive’
 Uncheck ‘delete records after archive before next step’(make sure the
 Touch ‘Done’
 Follow the onboard instruction
 Touch ‘Done’ when results back-up is finished
 Write the back-up date on the CD cover
is blank)
is blank)
3. Weekly QC in LIS
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
a. Login to SoftMic,
b. Click Results, click virology Worklist, double click Architect
c. Click ‘Yes’ in the following window
d. Press F12 key when the following window pops up
e. Finish the corresponding Architect-Weekly QC
4. Do architect inventory every Friday
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
XII.
Trouble shooting
Error
LIS is not responding
Action
1) At snapshot screen, touch ‘System’
2) Select ‘Configuration’
3) Select ‘Host release Mode’
4) Configure- click on' ON with Query' under 'Bidirectional
Host'
5) LIS Icon should appear on Snap Shot Screen.
6) If problem persists, contact Ed Cudek.
1005/Result cannot be
calculated, final RLU read is
outside the specification of the
lowest calibrator.
1) Spin sample at 10,000g(rcf) for 10 minutes and repeat
the test;
2) If the same error code persist, enter “PHL@MOH+” in
the LIS result.
3) Order send out test(e.g. 9VD) and send the specimen to
PHL for testing
1) Check connection of Dlink modem (little white box)
2) Check connection between instrument and LIS (purple
plug)
3) Turn off and restart the whole system in proper
sequence.
i.
To turn off the system:
a. Turn off computer first by touching ‘F3
shutdown’
b. Follow instruction till monitor screen goes
black
c. Press computer power switch
d. Turn off the architect
ii. To turn on the system
a. Press computer power switch
b. Wait the computer starting up until the
snapshot screen comes up
c. Turn on the architect instrument
4) If problem persists, call architect hotline
Both SCC (system control
center) and RSH (Robotic
sample handler) are ‘Offline’
Negative query received for
Sample ID (######)
1) Check if the tests are done in LIS
2) If the tests are not done:
 Order manually on Architect
 Download test through LIS
1) Log into Softlab
2) Click interfaces
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Cancel architect order from LIS
1.
2.
3.
4.
3) Double click instruments
4) Double click #6 ARCHI
5) Click loadlist on the top menu bar
6) Select ‘Build….’
7) Click ‘More>>’
8) Type the order twice at ‘Range of orders’
9) Click’OK’
10) Instrument Menu window pops up saying
‘# orders and # tests were added or
updated in the loadlist’
Click Interfaces
Double click Instrument Menu
Double click ARCHI
Click Loadlist at the top
5. Click Filter at the bottom
6. Change How to Display to: ‘By Order’
7. Type the order# at Starting From field only
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
8. Click OK
9. The specific order will appear at the very bottom of
the list
10. Highlight the order, all tests belong to this order
appear on the right panel
11. Click the test to be cancelled (e.g. 8HAG)
12. Click the Toggle Cancel Status x
13. Click Save symbol to save the cancellation
Save
Cancel Status
Test to be cancelled
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Instrument failure
1. Write down error code(s) in Architect Analyser History
Log book, call Abbott Technical Help Line@ 1-877422-2688 for instruction to solve the
problem(s).Instrument serial # is iSR06299.
2. If problem cannot be solved by the operator(s), Abbott
will send technical service specialist on site(Except
weekends and holidays).
3. If technical service specialist comes and replaces parts,
all Abbott controls have to be re-run before testing
patient samples.
4. Also run external control Virotrol for HBsAg.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
XIII.
Quality Control
Abbott Controls:
 Positive and negative controls must be run for all assays once per 24 hour shift. Always
run the positive control followed by the negative control.
 Control results are verified by a senior technologist and filed in Architect printout log.
 Run external control Virotrol for HBsAg after any service.
External Controls:
Select Packaging
Product
VIROTROL I
1 x 5ml
Cat # 00101
10 x 4 ml
VIROTROL II
1 x 5 ml
Class
F
HBsAg, Abbott Architect
Anti-HIV-1, Abbott Architect HIV ½ Ag/Ab combo1/2
Anti-HTLV-I, Abbott Architect
Anti-HBcore, Abbott Architect
Anti-HCV, Abbott Architect
Anti-CMV Total EIA, Abbott Architect
B+
Anti-HBs, Abbott Architect AUSAB (preferred)
Anti-HAV, Abbott Architect HAVAB 2.0 (preferred)
B
Anti-HBc IgM, Abbott Architect CORE-M
Anti-HAV IgM, Abbott Architect
C
HIV-2
N/A
HIV-1 (P24) Ag
N/A
All(except Rubella IgG)
N/A
CMV IgG
N/A
CMV IgM
N/A
Syphilis TP Ab
Cat # 00104
VIROTROL III
1 x 5 ml
VIROTROL HIV-2
Cat # 00105
1 x 5 ml
VIROTROL HIV-1 Ag
Cat # 00108
1 x 5 ml
Analyte, Test Method
VIROCLEAR
Cat # 00112
1 0x 4 ml
VIROToRCH
1 x 5 ml
Cat# 000109
VIROToRCH-M
1 x 5 ml
Cat# 000117
VIROTROL SYPHILIS
1 x 5 ml
Cat# 00071X
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
1. External Controls are entered in Architect External QC. All QC controls are verified by a senior
technologist.
2. If any external control result is out of range, withhold test results. Repeat with a new aliquot and
consult with Charge/senior technologists for review.
3. CAP, IQMH, and NML provide external proficiency testing
4. Calibrations: Run calibration for each new reagent lot or when control(s) fail.
5. Failed QC (Abbott controls and external controls): Test is invalid without satisfactory QC results.
Do not release reagent for use pending resolution.
XIV.
Reference
Abbott Operation Manual (201837-106).
Assay Packages inserts.
For Health Canada approved donor test licence numbers for non-TGLN donors Donor Serology
and Molecular Testing at Mount Sinai Hospital
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
George Washington Serology Study
I.
Introduction
George Washington serology study includes CMV IgG Avidity and Anti-HCV.
Infections with Cytomegalovirus (CMV), a member of the herpesvirus family, are common in
men and are usually mild and asymptomatic. However, in pregnant women, newborns, and
immunocompromised individuals CMV infections may pose a significant medical risk. CMV
infection remains difficult to diagnose on symptoms alone since a high percentage of infections
remains asymptomatic. In utero infection may result in sequelae of varying degrees including
mental retardation, chorioretinitis, hearing loss and neurologic problems. Since the risk of in utero
virus transmission and CMV related damage of the fetus is markedly increased during primary
infection, reliable recognition of primary CMV infection is of high importance for pregnant
women. Although presence of anti-CMV IgG reduces the likelihood of CMV related
complications, it does not assure complete protection from disease. The functional binding affinity
or avidity of IgG antibodies increases progressively over time after immunization, also known as
maturation of the humoral immune response. High percentage of low avidity IgG antibodies may
indicate a primary infection whereas high percentage of high avidity IgG antibodies may indicate a
recurrent infection.
The ARCHITECT CMV IgG Avidity assay is a qualitative method of the chemiluminescent
microparticle immunoassay (CMIA) for the determination of the avidity of IgG antibodies to
Cytomegalovirus in human serum and plasma. It is used as an aid in the differentiation between
primary and non-primary infection. If primary infection needs to be excluded, CMV IgG reactive
samples should be tested for CMV IgM and CMV IgG Avidity. A positive CMV IgM result in
combination with a low avidity result is a strong indicator for a primary CMV infection within the
last 4 months.
HCV is a bloodborne virus. The presence of anti-HCV indicates that an individual may have
been infected with HCV, may harbor infectious HCV, and/or may be capable of transmitting HCV
infection.
The ARCHITECT Anti-HCV assay is a qualitative method of the chemiluminescent
microparticle immunoassay (CMIA) for the detection of antibody to hepatitis C virus in human
serum and plasma.
II.
Specimen Type , Preparation and Storage
Specimen type
 Specimen collected (5mL for adult and 1mL for neonates) in serum separator tube potassium
EDTA tubed may be tested on Architect . Other specimen type refers to each assay package
insert.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual

Proficiency testing specimens must follow the accompanying guidelines for processing and
storage
Specimen preparation
 Follow the tube manufacture’s processing instructions for serum and plasma collection tubes.
Gravity separation is not sufficient for specimen preparation.
 Previously frozen specimens must be thaw thoroughly.
 Mix thawed specimens by low speed vortexing or by inverting 10 times. Visually inspect the
specimens. If layering or stratification is observed, continue mixing until specimens are
visibly homogeneous.
 To ensure consistency in results, specimens must be transferred to a centrifuge tube and
centrifuged at ≥10,000 RCF (Relative Centrifugal Force) for 10 minutes before testing if
- They contain fibrin, red blood cells, or other particulate matter,
- They require repeat testing, or
- They were frozen and thawed
Transfer clarified specimen to a sample cup or secondary tube for testing
 Centrifuged specimens with a lipid layer on the top must be transferred to a sample cup or
secondary tube. Care must be taken to transfer only the clarified specimen without the lipemic
material.
III.
Reagents and Bulk solutions






Abbott REAGENT KIT, CONTROL KIT, CALIBRATOR KIT : Must be carefully followed
the instruction in each assay package insert. Stored at 4 oC.
Abbot CONCENTRATED WASH BUFFER: Must be diluted prior to use. Contains 1.5M
phosphate buffered saline with antimicrobial agents. Stored at room temperature.
Abbott PRE-TRIGGER SOLUTION: Contains 1.32 %( w/v) hydrogen peroxide. Once
opened, placed on board the system no longer than 28 days, then discards. Stored at 4 oC.
Abbott TRIGGER SOLUTION: Contains 0.35N sodium hydroxide. Once opened, placed on
board the systems no longer than 28days, then discard. Stored at room temperature.
Abbott PROBE CONDITIONING SOLUTION: Contains recalcified human plasma; has
infection risk. Preservatives: Antimicrobial Agent and ProClin 300. Stored at 4 oC.
Ortho REAGENT KIT, CONTROL KIT: Must be carefully followed the instruction in
package insert. Stored at 4 oC.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
IV.
Materials and Equipment








ARCHITECT i System
ARCHITECT i System Assay CD-ROM
ARCHITECT i reaction vessels
ARCHITECT i sample cups
ARCHITECT i septum
ARCHITECT i replacement caps
Pipettes or pipette tips (optional)
EVOLIS ™ Analyzer
For information on materials required for maintenance procedures, refer to the ARCHITECT System and
Evolis analyser Operation Manuals.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
V.
Specimen Management for George Washington samples
Open box at specimen receiving
assigned area for George Washington
samples
Remove icepacks and dry ice, break
down boxes for recycling and discard
styrofoam
Open one canister at a time, remove
samples from packaging materials
Count the quantity of the sample per
canister and record on the manifest
Place the samples into a green plastic bin. Each
manifest order should have a separate bin
Discard canisters for plastic recycling
Move green bins to serology
accessioning area
Compare the recorded samples
number to the number on the manifest
Do the numbers match?
NO
Inform senior
technologist
YES
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Policy # MI/SER/v48
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Accession samples using the barcode
on the tubes
DO NOT MANULLY ENTER
Place large LIS barcode label on tube,
do not covering original barcode and
leaving sample number visible
Place small LIS barcode label on
manifest
Scan each tube into the excel manifest.
Verify proper tests were ordered. Take
special care with highlighted orders; those
that do not have the standard testing
panel: CMV IgG/CMV IgM/HCA
Centrifuge all samples
Bring all centrifuged samples to
Architect bench
VI.
Procedure
1. Refer to Architect SOP and Evolis SOP for maintenance.
2. Place Architect Anti-HCV, CMV-IgG R , CMV-IgM, and CMV Avidity reagents on the
system.
3. Make sure all reagents has been calibrated. Refer to Architect calibration procedure for
new lot calibration
4. Refer to Architect control procedure for Anti-HCV, CMV-IgG R, and CMV-IgM for
controls ordering
5. Load George Washington specimen onto architect system
6. Once all tests are finished, the ‘Result’ field will be flashing.
 Print: ‘Result lis Report’
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
7. Touch ‘Reruns’ from snapshot screen and delete all CMV-IgG reruns
8. Place all negative specimens in the aliquot rack. These specimens will be stored at -70 oC
for 6 months
9. Aliquot any specimen with the value of Anti-HCV is less than 5.00 S/CO and store them
in the positive CMV avidity + box (Freezer MIFTW beside the dark room).
10. For Anti-HCV ≥5.00S/CO, repeat Anti-HCV in duplicate on Architect:
1) Both results <5.00S/CO , Anti-HCV is Negative, make an aliquot and put in
positive CMV avidity + box (Freezer MIFTW beside the dark room)
2) One result<5.00S/CO and one result ≥5.00S/CO, Anti-HCV is Positive, place
an aliquot in the Evolis rack (MIRT8)
3) Both results≥5.00S/CO, Anti-HCV is Positive, place an aliquot in the Evolis
rack (Fridge MIRT8)
11. Refer Evolis SOP to run Anti-HCV
12. For CMV IgM≥1.00 Index & CMV IgG Reactive:
 Order CMV Avidity control(Control L= Level 1, Control H= Level 2):
1) Touch ‘Order’, Touch ‘Control order’
2) Scan in Carrier #. Type in position #
3) Touch box with bar
beside ‘Control’, highlight CMV Avidity
4) Make sure Level 1 is selected
5) In Assay panel, touch CMVAvidity
6) Touch ‘Add order’
7) Touch box with bar
beside ‘Control’, highlight CMV Avidity
8) Select ‘Level 2’
9) In the Assay panel, touch ‘CMVAvidity’
10) Touch ‘Add order’
11) Touch ‘Exit’ to go back snapshot screen
 Order CMV Avidity for patient’s specimen:
1) Touch ‘Order’, Touch ‘Patient order’
2) Scan in Carrier #. Type in position #
3) At SID field, scan in specimen order#
4) In panel field, touch CMV G>AV (CMV IgG R and zz-3009 are selected in
Assay panel)
5) Touch ‘Sample details’, type in Last name and First name
6) Touch ‘Done’, Touch ‘Add order’, Touch ‘Exit’
 Load CMV Avidity controls and patient’s specimen
 When CMV Avidity controls complete, print out the control list and release results
 Check patient specimen order status
1) Touch ‘Order’
2) Touch ‘Order Status’
3) Touch ‘C/P’
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual

4) Check the specimen order status
Proceed the following steps ONLY when both CMV IgG R and zz-3009
complete
! DO NOT RELEASE ANY RESULT YET


Check CMV IgG R result
1) If CMV IgG R≥250
i. Reload patient’s specimen onto Architect
ii. Once CMV IgG R completes with an end-point value, Reload specimen
onto Architect to get final CMV avidity result
2) If CMV IgG R<250,
i. Reload specimen onto Architect to get final CMV avidity result
Check patient’s CMV Avidity result
1) If CMV Avidity ≥50%
i. Print and release related results: CMVAvidity, CMVvi2, CMVAvi1,
zz_3009, CMV IgG R
2) If CMV Avidity<50%
i) Print and release all related results: CMVAvidity, CMVvi2, CMVAvi1,
zz_3009 , CMV IgG R
ii) CMV Avidity and CMV IgM must be repeated.
iii) Order CMV Avidity AND order CMV IgM at same time
iv) Load patient specimen onto Architect
v) Check patient specimen order status
a. Look for the specimen order status
vi) Proceed the following steps ONLY when both CMV IgG R and zz-3009
complete
! DO NOT RELEASE ANY RESULT YET
vii) Check CMV IgG R result
a. If CMV IgG R≥250
• Reload patient’s specimen onto Architect
• Once CMV IgG R complete, which has end-point value, Reload
specimen onto Architect to get final CMV avidity result
b. If CMV IgG R<250
Reload specimen onto Architect to get the final CMV avidity result
viii) Check the 2nd CMV avidity result
a. If CMV avidity result<50% (Matches the 1st avidity result)
 Pritn and release related results: CMVAvidity, CMVvi2,
CMVAvi1, zz_3009, CMV IgG R, CMV IgM
b. If CMV avidity result ≥50% (Does not match the 1st avidity result)
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Section: Serology Manual


Print and Release related results: CMVAvidity, CMVvi2,
CMVAvi1, zz_3009 , CMV IgG R, CMV IgM
Repeat one more CMV Avidity test to get 2/3 results
CMV Avidity Trouble Shooting
Unable to calculate CMV avidity due to high value of CMV IgG
 Perform 1:50 dilution on the specimen:
10µL specimen + 490 µL Architect Multi-Assay manual Diluent
 Repeat CMV avidity ONLY on architect (order CMV G>AV on Architect)
 Note: If CMV IgM must be repeated, use neat specimen.
13. Aliquot any CMV avidity positive specimen and store in CMV Avidity+ box (Freezer
MIFTW beside the dark room)
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Policy # MI/SER/v48
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Policy & Procedure Manual
Section: Serology Manual
VII.
GW CMV Avidity algorithm:
Load sample on to Architect
CMV IgM : Greyzone
Or
CMV IgM:
Nonreactive
Or
CMV IgM Positive but
CMV IgG Negative
CMV IgM : Reactive & CMV IgG Reactive
Manually Order CMV avidity on Architect and load sample
CMV IgG R≥250AU/mL
CMV IgG R<250AU/mL
Reload sample back on architect to do CMV IgG R dilution
Check if zz_3009 is completed before proceed next steps
Reload sample back on architect to do CMV avidity
Avidity ≥50%
Avidity<50%
Manually Order CMV avidity and CMV IgM on Architect
Load sample on to Architect
CMV IgG R≥250AU/mL
CMV IgG R<250AU/mL
Reload sample back on architect to do CMV IgG R dilution
Check if zz_3009 is completed before proceed next steps
Reload sample back on architect to do CMV avidity
Avidity<50%
Avidity ≥50%
Manually Order CMV avidity only on Architect
Load sample on to Architect
CMV IgG
R<250AU/mL
CMV IgG R≥250AU/mL
Reload sample back on architect to
do CMV IgG R dilution
Check if zz_3009 is completed before proceed next steps
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Reload
sample
back
to do
avidity
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Print and release results
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Section: Serology Manual
VIII.
GW Hepatitis C antibodies Algorithm:
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Microbiology Department
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Section: Serology Manual
IX.
CMV Avidity result reporting:
1) CMV Avidity≥50%, every results are autoverified except the following:
LIS order
Result
Comment
10CMR
Not Needed
Verify Result
2) CMV Avidity<50%, 2nd CMV AVIDITY <50%,
*Manually order 10CA2 in LIS
LIS order
Result
10CMA
1st CMV Avidity result
10CMR
Repeated CMV IgM result
10CA2
2nd CMV Avidity result
Comment
Verify Result
Verify Result
Verify Result
3) CMV Avidity<50%, 2nd CMV AVIDITY >50%, RUN ONE MORE CMV AVIDITY.
10CA2 and 10CA3 must be manually ordered in lis
 3RD CMV Avidity <50%
LIS order
Result
Comment
10CMA
1st CMV Avidity result
Verify Result
10CMR
Repeated CMV IgM result Verify Result
10CA2
2nd CMV Avidity result
Verify Result
10CA3
3RD CMV Avidity
 3RD CMV Avidity≥ 50%
LIS order
Result
10CMA
1st High CMV Avidity result
10CMR
Repeated CMV IgM result
10CA2
Low CMV Avidity result
10CA3
Last high CMV Avidity
Verify Result
Comment
Verify Result
Verify Result
Verify Result
Verify Result
4) Leave all CMV Avidity results print-out papers on Senior bench
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Section: Serology Manual
X.
Anit-HCV result reporting for Architect:
1) Initial Anti-HCV Reactive<5.00 S/CO
LIS Code
Result
8HCA
Negative
8HCA2
Architect value
8HCAE
Not processed
Comment
Verify result
Verify Result
In the comment , type ‘Test not
requested’ and Verify
2) Initial Anti-HCV≥5.00 S/CO
 Both duplicated Anti-HCV <5.00S/CO
LIS Code
Result
Comment
8HCA
Negative
Verify result
8HCA2
Negative
In the comment, type all 3HCA , Verify
Result
8HCAE
Not processed
In the comment , type ‘Test not
requested’ and Verify

One Anti-HCV<5.00 S/CO and one Anti-HCV≥5.00 S/CO
LIS Code
Result
Comment
8HCA
Check#
Do NOT Verify
In the comment, type all 3 HCA results
separated by /
(e.g.:### / ### / ###)
8HCA2
Type two repeated
Verify Result
HCA results
8HCAE
Leave blank
Do NOT Verify

Both duplicated Anti-HCV ≥5.00 S/CO
LIS Code
Result
Comment
8HCA
Check#
Do NOT Verify
In the comment, type all 3 HCA results
separated by /
(e.g.:### / ### / ###)
8HCA2
Type two repeated
Verify Result
HCA results
8HCAE
Leave blank
Do NOT Verify
14. Final reporting after 8HCAE results available from Evolis
 8COM must be ordered after initial 8HCAE result is available
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
XI. Reference
Abbott Operation Manual (201837-106).
Assay Packages inserts.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
HCV Ab EIA Serology for George Washington
I.
Introduction
ORTHO HCV 3.0 ELISA Test System with Enhanced SAVe is a qualitative, enzyme-linked
immunosorbent assay for the detection of antibody to hepatitis C virus (anti-HCV) in human
serum or plasma.
II.
Specimen Collection and Processing
a. Blood, serum or plasma collected by clients.
b. If blood tube received, centrifuge at 3000 rpm for 10 minutes.
III.
Instrument
EVOLIS ™ Analyzer
IV.
Reagents
1. Hepatitis C Virus(HCV) encoded Antigen coated Microwell plates (5)
2. Conjugate-Antibody to Human IgG(Murine Monoclonal)-anti-human IgG heavy
chain(murine monoclonal) conjugated to horseradish peroxidase with stabilizers
3. Specimen Diluent
4. OPD tablets(30) contains o-phenylenediamine∙2HCL
5. Substrate Buffer-citrate-phosphate buffer with 0.02% hydrogen peroxide
6. Positive Control(Human)
7. Negative control(Human)
V.
Preparation
1. Before beginning EIA assay, fill up Ortho wash buffer container (yellow tubing) when
necessary:
*Working Orthodiagnostic Wash buffer: Add 100ml of 20X Ortho wash solution
to 1900 ml of distilled water
2. De-ionized Water: Fill up Evolis containers (blue and red tubing) with de-ionized water
3. Transfer the ORTHO (4N sulfuric acid) Stop Solution into a 60ml EVOLIS container,
4. Aliquot HCV Ab and controls into separate 2ml sample containers,
*When transferring solutions, use new containers for each new Lot #. Always have
name, lot number, expiration date and date transferred.
5. Bring microwell plates and the above mentioned reagents to room temperature before
use.
6. Empty the waste tank and check the system liquid container (refill if necessary).
System Liquid Preparation: 2 ml of Tween 20 to 10L of de-ionized water.
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Microbiology Department
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Section: Serology Manual
VI.
Procedure
1 Turn “ON” the EVOLIS analyzer first and then the computer at the beginning of the day.
2 Double click on the EVOLIS icon located on the computer desk-top.
3 Log onto the system by clicking on “OK”, no password is required.
4 A self-test of the system is automatically initialized each time the EVOLIS software is run. The
self-test is considered satisfactory if the word “PASSED” appears beside each instrument
module. Print a copy of the self-test report and combine it with the worklist and result sheets.
5 Make specimen tasklist. Prepare specimens by removing the lids and loading all sample tubes
with the barcode visible (facing out) on the sample rack (rack code T).
6 Check the quality of the samples by ensuring all clots, foam and bubbles have been removed.
7 Open the door to the sample and reagent unit. Load the sample rack with the bar-codes facing
the bar-code reader onto the track marked by the solid red LED light.
8 The ‘Patient Editor’ dialog box will appear with the specimen numbers from the loaded rack.
Double check that the specimen numbers and test are correct. If there is a blank space under
the patient ID column, click on the space and enter the specimen number manually. All
specimen numbers entered manually will be flagged with the code “ManID” on the results
report.
9 Choose the assay from the drop down menu which appears along the top of the Patient Editor
dialog box, use the scroll bar at the bottom of the dialog box to select additional assays :
HCV_Ab assay= ACHCV_ORTHO
10 A check mark is shown for a sample where the HCV Ab assay has been selected.
11 Once HCV Ab assay has been selected for each sample click ‘Close’ to save. A solid LED
light will show up for the next available track in the sample and reagent unit which indicates
where the next sample rack can be loaded. Repeat steps 6 to 11 for each new sample rack that
is loaded on to the analyzer.
12 A total of four sample racks need to be loaded on to the analyzer even if all the sample racks
are not required, in order for the reagent template to be used in a later step. When an empty
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Section: Serology Manual
sample rack is loaded on to the analyzer just click ‘Close’ when the Patient Editor dialog box
appears.
13 To check and validate the worklist click on the ‘New Worklist’ icon located on the upper
toolbar and the Set-Up dialog box will appear.
14 Click on the “+” next to each plate to see which assay is programmed for which plate. Click
on “+” beside the assay file name that is associated with each plate. The plate layout will
appear at the right hand side of the dialog box and will show the total number of controls and
specimens to be tested, their assigned wells and the number of strips required for each assay.
Print plate layout.
15 If duplicate samples need to be tested :
a) From the Patient Editor dialog box select the assay folder in which the duplicate
sample needs to be run and click ‘Add Patient’.
b) The Select Patient(s) dialog box will appear.
c) Check the Allow multiple determinations box which appears at the bottom of the
Select Patient|(s) dialog box.
d) The patient sample IDs will appear. Click on the sample ID in which multiple testing is
required and click OK.
e) In the Set-up Panel dialog box, a (x2) will appear beside the patient ID under the assay
folder in which it was selected.
16 If all the information is correct click ‘OK’ to validate the worklist.
17 A separate dialog box asking for the reagent lot numbers will appear d. Double check the lot
numbers and expiry dates and click ‘OK’ if everything is correct.
18 Click on the “+” to expand the Work folder and click on ‘Plate Layout’, the number of
microwell strips required for each assay can be reviewed. Click the ‘Print’ button located
along the top of the toolbar to print the plate layout if desired.
19 Click ‘START’ (green button) located on the upper tool bar to open the Load dialog box.
20 The Load dialog box appears and shows where to load all the required resources
21 Load all required resources from left to right:
a) HCV Sample Diluents
b) Pipette tips: Grey = 1100 ul tips (full rack)
Brown= 300 ul tips (full rack)
Red = Incomplete tip rack
*The pipette tips have to be loaded in the exact position as shown in the layout
c) Load the reagents on the reagent racks according to the following templates
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(Figure 1-3).
d) Ensure all caps on the reagent/control containers have been removed before loading
them onto the analyzer.
22 Manually Assigning Reagent Locations—Only if Necessary
a) Load the reagents and controls into the desired positions on the reagent racks and load
the racks onto the analyzer. The reagent racks will appear blank when loaded.
b) Different coloured circles representing the reagents/controls will be found at the right
hand column of the Load dialog box under the section ‘Unallocated Resources’.
Moving the mouse over each circle tells you which reagent/control it represents.
c) Click on the circle and drag it over to the correct position in which the reagent/control
has been placed on the reagent rack.
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Section: Serology Manual
d) The position of bar-coded reagent/control containers do not have to be manually
assigned, their location would be read by the bar code reader.
23 Once all the reagents and controls have been added to the racks, load the reagent racks into the
sample and reagent unit in the following order:
a) 1st ‘0’- Large reagent rack
b) 2nd ‘1’- Medium reagent rack
c) 3rd ‘3’- Small reagent rack
24 In the Load dialog box, click the ‘Open Reagent Layout’ button. Select the file name HCV
only and click ‘Open’. All reagents and controls will be automatically allocated to their assign
position.
25 Once all the required resources have been loaded onto the analyzer click ‘OK’ and the Load
dialog box will disappear. The analyzer will begin to check the resources to ensure their
amounts are sufficient.
26 The Load Plate dialog box will then appear. Rename the plate ID with HCV and check the lot
and expiration date.
27 Insert the microplate making sure that the A1 position of the plate and holder match each other.
28 Click ‘OK’.
29 After the microplate is loaded, the analyzer will start to run automatically.
30 From the Work folder click on ‘Schedule’ to view the chorological order and completion time
of the run. Take note of the amount of time required before operator intervention is needed
(for OPD preparation and loading). Prepare the required OPD substrate in a 30ml Evolis vial
before operation intervention is necessary and store the OPD in a dark location before loading
is required.
31 While the samples are being pipetted click on ‘Active Event Log’ to ensure that all samples
were pipetted successfully. Look for any red flags that may appear in the “Dispense Sample”
section which indicates that an error has occurred. The analyzer will pause and flag with an
error message if a clot or low sample volume is encountered, allowing for operator
intervention. It will specify position on rack and where and how much of the sample to
transfer on the microplate.
32 Prepare orthodiagnostic HCV Ab OPD Substrate within 1 hour before the intervention is
requied
1 OPD tablet + 6 ml of Substrate Buffer for 1 – 3 strips
2 OPD tablet + 12 ml of Substrate Buffer for 4 – 7 strips
33 There are 2 alarms requiring operator intervention. After the second alarm and the Load dialog
box will appear with the message: ‘Please load the requested items as soon as possible as the
system is paused’.
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Section: Serology Manual
34 Open the door to the sample and reagent unit and place the OPD substrate to the correct
location without removing the reagent rack from the analyzer. Close the door to the sample
reagent unit and click ‘OK’ in the computer.
35 Once the HCV Ab assays is finished a dialog box prompting the removal of the plate and
carrier from the analyzer will appear.
36 Remove the microplate and click ‘OK’.
37 A blinking red LED light in the sample and reagent unit indicates that the reagent or sample
racks can be unloaded from the analyzer.
38 Remove all samples and diluents from the dilution area.
39 Do not unload pipette tip racks from the analyzer unless they are completely empty.
40 The results report will automatically be printed after each assay is completed.
41 Close the EVOLIS software. Select File | Exit from the menu bar or click the X icon at the top
right-hand corner of the Evolis software and shut down the computer.
42 Switch off the Evolis analyzer.
43 Open the instrument cover and wipe the tip adapter (pipettor head) with 70% Ethanol wipes.
44 Empty the liquid waste container.
45 Empty the bag for the tip waste container and replace if damaged.
46 Inspect the instruments (inner and outer surfaces) and racks for stains and spills. Clean if
necessary.
VII.
Weekly Maintenance Procedure :
a) Run the weekly washer maintenance: (Procedure takes approximately 20 min)
i. Fill all wash buffer containers with de-ionized water
ii. Click ‘New Worklist’ located in the upper toolbar
iii. The Set-up panel dialog box will appear
iv. In the Set-up Panel dialog box click ‘Add Plate’
v. In the Set-up Panel dialog box click ‘Add Assay’ and then select the file
‘WasherClean BR.asy’, click ‘Open File’.
vi. Click ‘OK’ to validate the various dialog boxes until the worklist appears.
vii. Click ‘Start’ (green button)
viii. Load an empty washer microplate with the metal plate holder onto the analyzer
when the Load Plate dialog box appears. Click ‘OK’ after the plate is loaded
onto the analyzer.
ix. When the run is complete, unload the washer plate and replace the de-ionized
water with the appropriate wash buffers.
*The weekly washer maintenance does not have to be completed during the week
the monthly washer maintenance is being done.
b) Decontaminate the pipettor wash station:
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Section: Serology Manual
i. Pour 5 ml of decontamination solution consisting of 0.4% RIVASCOP (4ml of
RIVASCOP into 1L of water) into the pipettor wash station and let it soak for
a minimum of 15 minutes.
ii. Do not empty, the liquid will drain automatically when the system is initialized.
c) Decontaminate and wipe the tip ejection slide.
d) Clean the instrument surfaces and work area.
VIII. Monthly maintenance Procedure:
a. Run the monthly washer maintenance: (Procedure takes approximately 1 hour)
i.
ii.
iii.
iv.
v.
Fill all the wash buffer containers with de-ionized water
Click ‘New Worklist’ located in the upper toolbar
The Set-up panel dialog box will appear
In the Set-up Panel dialog box click ‘Add Plate’
In the Set-up Panel dialog box click ‘Add Assay’ and then select the file
‘WasherManifoldDisinfect BR.asy’, click ‘Open File’
vi. Click ‘OK’ to validate the various dialog boxes until the worklist appears.
vii. Click ‘Start’ (green button)
viii. The Load dialog box will appear.
ix. Pour 50ml of 0.4 % RIVASCOP into two 60ml of container and load the
reagents onto a ‘0’ reagent rack. Then load the rack onto the analyzer.
x. In the Load dialog box, allocate the bottles to the corresponding rack position in
which the container was loaded then click ‘OK’.
xi. Load an empty washer microplate with the metal holder onto the analyzer when
the Load Plate dialog box appears. Click ‘OK’ after the plate is loaded onto the
analyzer.
xii. A few minutes later a message saying to ‘open the drawer, unscrew waste bottle
1 and close the drawer’ will appear.
xiii. Unscrew the cap to waste bottle 1, which is located behind the wash buffer
bottles. Close the drawer when done and click ‘OK’.
xiv. After 15 minutes a message prompts you to re-open the drawer and re-screw the
cap to waste bottle 1, close the drawer when completed and click ‘OK’.
xv. When the run is complete, unload the plate and the reagent rack and replace the
de-ionized water with the appropriate wash buffers.
b. Decontaminate the sample and reagent racks, plate carrier and tip ejection slide.
c. Decontaminate the system liquid container
i. Empty the system liquid container.
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Section: Serology Manual
ii. Empty the container and rinse thoroughly, twice with tap water and once with
de-ionized water.
iii. Inspect the filter (attached to the cap) to see if damaged or in need of replacing.
iv. Refill the container with freshly prepared System Liquid.
Preparation of System Liquid: 2 ml of Tween 20 to 10L of de-ionized water.
d. Clean the washer buffer bottles only and NOT the caps & sensor devices.
e. Backup System Files
i. Click ‘Backup’ button found at the upper tool bar.
ii. The System Backup dialog box will open up.
iii. Click ‘Backup System Files’
iv. Once completed, click ‘Close’ from the System Backup dialog box.
IX.
Assay validation:
1. Substrate Blank Acceptance: The Substrate Blank (A1 well) > = -0.020 and < = 0.05
2. Negative Calibrator Acceptance: Each Negative Control must < = 0.120 and > = -0.005.
Negative Calibrator with absorbances between 0.000 and –0.005 are rounded to 0.000 for
calculations. If one of the three Negative Calibrators is outside the acceptable range, the
calculations are made based on the two acceptable Negative Calibrators. The plate is
invalid and should be repeated, if two or more of the Negative Calibrators are
unacceptable.
3. Calculate the mean of the Negative Calibrators.
4. Positive Control Acceptance: Both Positive Controls must be > = 0.800. Both Positive
Controls must not differ by more than 0.600
5. Cutoff Value Calculations: Cutoff = NCal mean + 0.600
X.
Quality Control:
All positive controls and negative controls should all within the range as mentioned in the Kit
insert. If any control fails, withhold test results. Inform Charge/Senior technologists.
Run Virotrol 1 & viroclear monthly/new lot for HBsAg,HIV ½,HBcAb and HCV Ab. Results
entered in Non-AXSYM external Control Spreadsheet. Repeat with a new aliquot if Virotrol 1
fails. Inform Charge/Senior technologists.
XI.
Reporting:
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Section: Serology Manual
1. Positive: >Cutoff Value
2. Negative: < Cutoff Value
3. All positive specimens will be repeated x 2 on the next run. Sample should be obtained
from the original blood tube.
4. All repeats have to be recorded on the EVOLIS REPEATS WORKLIST, and given when
complete to the chief LIS officer.
5. Reporting for George Washington 8HCAE
 8COM must be ordered after initial 8HCAE result is available
 8HCA must be resulted using the following format in the comment-3 architect
values must be above the test comment:
#.## / #.## / #.##
(Test performed using the Architect Anti-HCV assay,
device #6C37,Abbott Diagnostics)
1) Initial 8HCAE is Negative
LIS Code
Result
8HCA
Inconclusive
8HCA2
8HCAE
8COM
Type two repeated HCA
results
Negative
Note
Comment
 3 architect values in the comment
(e.g.:#.## / #.## / #.##)
 Verify 8HCA
 Verify Result
 Verify 8HCAE
 In the comment for 8COM, record
O.D. results for HCAE and cut off
O.D. from initial run
 Verify 8COM
2) Initial 8HCAE is Positive, both repeated 8HCAE2 are Positive, or
Initial 8HCAE is Positive, one repeated 8HCAE2 is positive and on repeated
8HCAE2 is negative
LIS Code
Result
Comment
8HCA
Positive
 3 architect values in the comment
(### / ### / ###)
 Verify 8HCA
8HCA2
Type two repeated HCA
results
 Verify Result
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8HCAE
Positive
8HCE2
8COM
Positive
Note
 Enter 3 Evolis results as
 pos/pos/neg
 Verify 8HCAE
 Verify 8HCE2
 In the comment for 8COM, record 3
O.D. results for HCAE and cut off
O.D. from initial and repeat runs
 Verify 8COM
3) Initial 8HCAE is Positive, both repeated 8HCAE2 are Negative
XII.
LIS Code
8HCA
Result
Inconclusive
8HCA2
8HCAE
Type two repeated HCA
results
Negative
8HCE2
8COM
Negative
Note
Comment
 3 architect values in the comment
(e.g.:### / ### / ###)
 Verify 8HCA
 Verify Result
 Type 3 Evolis results as
pos/neg/neg
 Verify 8HCAE
 Verify 8HCE2
 In the comment for 8COM, record
3 O.D. results for HCAE and cut
off O.D. from initial and repeat
runs
 Verify 8COM
Troubleshooting Procedures
For Flags, Recalculate Results and other procedures please refer to Evolis Short User Manual
(Quick guide) Chapter 3: Advanced Information.
For more information please refer to Evolis User Manual 1.90 EN (Long Version)
If service is needed:
Call BioRad Service: 1-800-361-1808 for Evolis problems.
Instrument SN: 9163740225
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Section: Serology Manual
XIII. Reference
Package insert from Ortho®HCV 3.0 ELISA Test System, revised July 2003
EVOLIS™ Short User Manual software version 1.90, revised June 2008
EVOLIS™ User Manual software version 1.90, revised June 2007
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Section: Serology Manual
Hepatitis Virus Serology
Although there are many infectious causes of hepatitis, the majority are caused by hepatitis A, B and C
viruses. Acute Hepatitis A is diagnosed by detection of IgM antibodies. Anti-HAV IgM becomes
positive just before the development of clinical hepatitis and remains positive for at least 4 months after
infection. There is no chronic carrier state for Hepatitis A. Detection of total antibodies to Hepatitis A
indicates immunity due to either past infection or immunization.
Hepatitis B is diagnosed by either detecting hepatitis B surface antigen (HBsAg) which indicates the
presence of infectious virus, (HBcAb-IgM) or Anti-hepatitis B surface antibodies (HBsAb) which
indicate immunity due to either past infection or immunization. Anti-hepatitis B core IgM antibodies
indicate acute infection and HBcAb-Total indicates previous or current infection. HBsAg should be
cleared within 6 months of acute infection. Persistence of HBsAg beyond 6 months is consistent with
chronic hepatitis B infection. Some of these tests may occasionally be performed on a STAT basis
because of concern regarding transmission of the virus to a susceptible individual following exposure (i.e.
needlestick, newborn) to infected blood/body fluids and the need to prevent the disease by administering
vaccine and/or immunoglobulin.
Hepatitis due to the delta virus is rare in Canada. It only occurs in association with patients who are
positive for hepatitis B surface antigen. Requests for this virus should be forwarded to the Public Health
Laboratory.
Hepatitis C (HCV) is a blood borne virus closely associated with blood transfusion and intravenous drug
use. The presence of antibodies to HCV indicates that an individual may have been infected with HCV,
may harbour infectious HCV and\or may be capable of transmitting HCV infection.
The following requests will be handled in our laboratory:
Hepatitis B surface antigen
HBsAg
Hepatitis B surface antibody
HBsAb
Hepatitis B core antibody
HBcAb
Hepatitis B e antigen
HBeAg1
Hepatitis B e antibody
HBeAb1
Hepatitis C antibody
HCA
Hepatitis A IgM antibody
HAV-IgM2
Hepatitis A Total antibody
HAV-IgG
Note: 1)
These tests will be performed on request only if the patient is HBsAg positive.
2)
Perform only HAV-IgM if type of Hepatitis A test is not specified.
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Section: Serology Manual
Table 1. Tests performed as per designated categories
Clinical Category
Hepatitis B Screen
Hepatitis A Screen
Hepatitis B Immune Status
Needlestick
- Patient (source)
- Staff (exposed)
Pre/postnatal
- Mother
Hepatitis Screen
HBsAg
X
Test Performed
HBsAb
HAV-IgM
HCVAb
X
X
X
X
X
X
X
X
X
X
For additional requests within the above categories, consult with the charge technologist or medical
microbiologist. In the absence of one of the above clinical categories, do the tests as requested.
Table 2. Guidelines for STAT Testing
Clinical
setting
Serum
tested
Time frame
from exposure
to report
Days of
week
Callback
Neonate
Prenatal
Needlestick/
mucosal exposure2
Renal dialysis
Mother
Mother
See below
< 12 hours
< 12 hours
< 72 hours
All
All
All
No1
No1
No1
Patient
< 12 hours
All
No1
1) May require call back on weekends if time from exposure to reporting exceeds 12 hours. Must be
approved by microbiologist on-call.
2) Perform HBsAg and HCVAb on the source. Test HBsAb and HCVAb on the employee.
Whichever of these arrives first is to be tested STAT. If both arrive at the same time, test both
simultaneously. If the source HBsAg is positive, test the employee STAT. If the source is
negative, test employee in the next routine run.
Labor Delivery Stat HIV HBsAg Instructions
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Microbiology Department
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Section: Serology Manual
Aspergillus Galactomannan Antigen Detection Assay
I.
Introduction
The PlateliaTM Aspergillus EIA is a qualitative enzyme immunoassay for the detection of
Aspergillus galactomannan antigen in serum and Bronchoalveolar Lavage (BAL) samples.
II.
Specimen Collection and Processing
The test is performed on serum and BAL samples. Blood is collected in a serum separator tube
and separated by centrifugation at 3000 rpm for 10 minutes. After initial opening, samples
may be stored at 2-8oC for up to 48 hours prior to testing. For longer storage, store the serum
at -70oC.
III.
Instrument
EVOLIS ™ Analyzer
IV.
Reagents
BioRad Aspergillus Galactomannan kit:
1. Galactomannan monoclonal antibodies coated microwell plate
2. Concentrated wash solution (10X)
3. Negative control serum (Human) Cut-off control serum (Human) Positive control
serum (Human)
!The controls must be heat-treated with the Sample Treatment Solution as
patient specimens, in order to also be a monitor of the treatment
4. Conjugate – Anti-galactomannan monoclonal antibody/ peroxidase labeled
5. Sample Treatment Solution (EDTA acid solution)
6. TMB substrate buffer
7. Chromogen TMB solution
8. Stopping solution – 1.5N sulphuric acid
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V.
Preparation for Procedure
7. Before beginning EIA assay, fill up Galactomannan BioRad Wash containers when
necessary:
*Working Galactomannan Wash buffer: Add 50 ml of 20x BioRad wash solution
to 950 ml of distilled water.
Fill up Galactomannan wash container with black tubing
8. De-ionized Water: Fill up Evolis blue, yellow and red tubing container with de-ionized
water
9. Working TMB substrates are prepared fresh for each run in a 30ml EVOLIS vial.
10. The Aspergillus Galactomannan conjugate and stopping solution will be pipetted from
their original containers and can be loaded onto the analyzer as is.
11. Bring all required microwell strips and the reagents mentioned above to room
temperature before use.
12. Empty the waste tank and check the system liquid container (refill if necessary).
System Liquid Preparation: 2ml of Tween 20 to 10L of de-ionized water.
VI.
Treatment of the serum/BAL Fluid
Serum and BAL samples need to be heat-treated in the presence of EDTA prior to being tested
on the analyzer. This pre-analytical procedure helps dissociate immune complexes and causes
serum proteins to precipitate which can possibly interfere with the testing procedure.
All control sera: negative, cut-off and positive must be processed at the same time and in the
same manner as the patient samples:
1. Label 2 empty 2ml sample tubes. One tube must labelled with the patient barcode
label. For the control samples label 2 empty tubes for each: Neg, Cut-Off & Pos,
respectively.
*The Cut-Off Control will be sampled twice by analyzer but only one sample tube
needs to be prepared.
2. Pipette 390ul of each test serum/BAL or control into one of the 2 ml sample tubes.
3. Add 130ul of serum treatment solution into the sample tube.
4. Tightly close the caps of the tubes to prevent opening during heating.
5. Mix tubes thoroughly by vortexing each sample.
6. Heat the sample tubes by placing them in a heating block at 120oC for 6 minutes.
Tubes must be placed in the block only when the prescribed temperature is reached.
7. Carefully remove the heated tubes from the heating block after 6 minutes and place
them in the centrifuge. Centrifuge tubes at 10,000 x g for 10 minutes. The supernatant
is used for the detection of the galactomannan antigen.
8. Transfer 300ul of supernatant into the second labeled 2ml sample tube which has
patient’s bar code and will be placed on to the EvolisTM analyzer.
9. After preparation, the supernatant may be removed and stored at 2-8 oC for up to 48
hours prior to testing. If analysis of the results indicates that retesting of a sample is
required, another aliquot of the serum or BAL must be heat treated for retesting.
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VII.
Procedure
1. Log onto the system by clicking on “OK”, no password is required.
2. A self-test of the system is automatically initialized each time the EVOLIS software is
run. The self-test is considered satisfactory if the word “PASSED” appears beside each
instrument module. Print a copy of the self-test report and combine it with the work list
and result sheets.
3. Prepare specimens by removing the lids off the heat-treated serum/BAL supernatant
and load all sample tubes with the barcode facing right on to the sample rack (rack code
T). Check the quality of the samples by ensuring all clots, foam and bubbles have been
removed.
4. Open the door to the sample and reagent unit. Load the sample rack with the bar-codes
facing the bar-code reader onto the track marked by the solid red LED light.
5. The ‘Patient Editor’ dialog box will appear with the specimen numbers from the
loaded rack. Double check that the specimen numbers are correct. If there is a blank
space under the patient ID column, click on the space and enter the specimen number
manually. All specimen numbers entered manually will be flagged with the code
“ManID” on the results report.
6. Choose the Galactomannan assay from the drop down menu which appears along the
top of the Patient Editor dialog box:
Galactomannan assay = “MT SINAI Aspergillus EIA New BR V1”
7. Click on the assay box corresponding to the sample number if you want that assay to be
run for that sample. A check mark is shown for a sample where the assay has been
selected.
8. Once the required assay has been selected for each sample click ‘Close’ to save. A
solid LED light will show up for the next available track in the sample and reagent unit
which indicates where the next sample rack can be loaded. Repeat steps 6 to 11 for
each new sample rack that is loaded on to the analyzer.
9. A total of four sample racks need to be loaded on to the analyzer even if all the sample
racks are not required in order for the reagent template to be used in a later step. When
an empty sample rack is loaded on to the analyzer just click ‘Close’ when the Patient
Editor dialog box appears.
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10. To check and validate the worklist click on the ‘New Worklist’ icon located on the
upper toolbar and the Set-Up dialog box will appear.
11. Click on “+” beside the assay file name that is associated with the plate. The plate
layout will appear at the right hand side of the dialog box and will show the total
number of controls and specimens to be tested, their assigned wells and the number of
strips required for the assay.
12. If duplicate samples need to be tested for a given assay in the same run:
a) From the Patient Editor dialog box select the assay folder in which the
duplicate sample needs to be run and click ‘Add Patient’.
b) The Select Patient(s) dialog box will appear.
c) Check the Allow multiple determinations box which appears at the bottom of
the Select Patient|(s) dialog box.
d) The patient sample IDs will appear. Click on the sample ID in which multiple
testing is required and click OK.
e) In the Set-up Panel dialog box, a (x2) will appear beside the patient ID under the
assay folder in which it was selected.
13. If all the information is correct click ‘OK’ to validate the worklist.
14. A separate dialog box asking for the reagent lot number will appear for each assay that
is ordered. Double check the lot number and expiry date and click ‘OK’ if everything
is correct.
15. Click on the “+” to expand the Work folder and click on ‘Plate Layout’, the number of
microwell strips required for the assay can be reviewed. Click the ‘Print’ button
located along the top of the toolbar to print the plate layout if desired.
16. Click ‘START’ (green button) located on the upper tool bar to open the Load dialog
box.
17. The Load dialog box appears and shows where to load all the required resources.
18. Load all required resources from left to right:
i. Pipette tips: Grey = 1100 ul tips (full rack)
Brown= 300 ul tips (full rack)
Red = Incomplete tip rack
*The pipette tips have to be loaded in the exact position as shown in the layout
ii. Load the assay reagents on the reagent racks according to the following templates
(Figure 1). The reagent template specific for the Aspergillus Galactomannan assay
should be used.
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iii. Ensure all caps on the reagent/control containers have been removed before loading
them onto the analyzer.
TMB Substrate preparation for Aspergillus Galactomannan assay (prepare in
30ml coated vial):
Prepare Fresh (Same Day) Working Chromogen as follows (always make 1 extra
strip):
Number of Strips Chromogen Reagent (uL) Chromogen Diluent
(mL)
1
2
3
4
5
40
80
120
160
200
2.0
4.0
6.0
8.0
10.0
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Figure 1
Once all the reagents and controls have been added to the racks, load the reagent racks
onto the sample and reagent unit in the following order:
1st =‘0’- Large reagent rack
2nd=‘3’- Small reagent rack
iv. In the Load dialog box, click the ‘Open Reagent Layout’ button. Select the file name
‘galactomannan.rea’ and click ‘Open’. All reagents and controls will be
automatically allocated to their assign position.
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Section: Serology Manual
19. Once all the required resources have been loaded onto the analyzer click ‘OK’ and the
Load dialog box will disappear. The analyzer will begin to check the resources to
ensure their amounts are sufficient.
20. The Load Plate dialog box will then appear. Rename the plate ID with the
corresponding assay name, for example Galactomannan. The test date will
automatically be added to the plate ID by the analyzer.
21. Prepare the required number of microwell strips for the requested assay. The number
of strips required is shown in the Plate Layout which is found on the right hand side of
the Load Plate dialog box.
22. Insert the microplate into the metal frame microplate holder. Make sure that the A1
position of the plate and holder match.
23. Open the door to the microplate loading compartment and load the microplate and its
holder onto the plate transport unit. Once loaded, close the door to the microplate
loading compartment.
24. Once the plate is loaded click ‘OK’. After the microplate is loaded, the analyzer will
start to run automatically.
25. From the Work folder click on ‘Schedule’ to view the chorological order and
completion time of the run.
26. While the samples are being pipetted click on ‘Active Event Log’ to ensure that all
samples were pipetted successfully. Look for any red flags that may appear in the
“Dispense Sample” section which indicates that an error has occurred. The analyzer
will pause and flag with an error message if a clot or low sample volume is
encountered, allowing for operator intervention.
27. The results report will automatically print out after the assay is completed.
28. Once the assay is finished a dialog box prompting the removable of the test plate and
carrier from the analyzer will appear.
29. Open the door to the microplate loading compartment and remove the microplate.
After the microplate is unloaded close the door to the microplate loading compartment
and click ‘OK’.
30. A blinking red LED light in the sample and reagent unit indicates that the reagent or
sample racks can be unloaded from the analyzer.
31. Do not unload pipette tip racks from the analyzer unless they are completely empty.
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Section: Serology Manual
32. Close the EVOLIS software. Select File | Exit from the menu bar or click the X icon at
the top right-hand corner of the Evolis software and shut down the computer.
33. Switch off the Evolis analyzer.
34. Open the instrument cover and wipe the tip adapter (pipettor head) with 70% Ethanol
wipes.
35. Empty the liquid waste container.
36. Empty the bag for the tip waste container and replace if damaged.
37. Inspect the instruments (inner and outer surfaces) and racks for stains and spills. Clean
if necessary.
VIII.
Weekly Maintenance Procedure :
1. Run the weekly washer maintenance: (Procedure takes approximately 20 min)









Fill all wash buffer containers with de-ionized water
Click ‘New Worklist’ located in the upper toolbar
The Set-up panel dialog box will appear
In the Set-up Panel dialog box click ‘Add Plate’
In the Set-up Panel dialog box click ‘Add Assay’ and then select the file
‘WasherClean BR.asy’, click ‘Open File’.
Click ‘OK’ to validate the various dialog boxes until the worklist appears.
Click ‘Start’ (green button)
Load an empty washer microplate with the metal plate holder onto the
analyzer when the Load Plate dialog box appears. Click ‘OK’ after the
plate is loaded onto the analyzer.
When the run is complete, unload the washer plate and replace the deionized water with the appropriate wash buffers.
*The weekly washer maintenance does not have to be completed during
the week the monthly washer maintenance is being done.
2. Decontaminate the pipettor wash station:

Pour 5 ml of decontamination solution consisting of 0.4% RIVASCOP (4ml
of RIVASCOP into 1L of water) into the pipettor wash station and let it
soak for a minimum of 15 minutes.
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
Do not empty, the liquid will drain automatically when the system is
initialized.
3. Decontaminate and wipe the tip ejection slide.
4. Clean the instrument surfaces and work area.
IX.
Monthly maintenance Procedure:
1. Run the monthly washer maintenance: (Procedure takes approximately 1 hour)















Fill all the wash buffer containers with de-ionized water
Click ‘New Worklist’ located in the upper toolbar
The Set-up panel dialog box will appear
In the Set-up Panel dialog box click ‘Add Plate’
In the Set-up Panel dialog box click ‘Add Assay’ and then select the file
‘WasherManifoldDisinfect BR.asy’, click ‘Open File’
Click ‘OK’ to validate the various dialog boxes until the worklist appears.
Click ‘Start’ (green button)
The Load dialog box will appear.
Pour 50ml of 0.4 % RIVASCOP into a 60ml of container and load the reagent
onto a ‘0’ reagent rack. Then load the rack onto the analyzer.
In the Load dialog box, allocate the bottle to the corresponding rack position in
which the container was loaded then click ‘OK’.
Load an empty washer microplate with the metal holder onto the analyzer when
the Load Plate dialog box appears. Click ‘OK’ after the plate is loaded onto
the analyzer.
A few minutes later a message saying to ‘open the drawer, unscrew waste bottle
1 and close the drawer’ will appear.
Unscrew the cap to waste bottle 1, which is located behind the wash buffer
bottles. Close the drawer when done and click ‘OK’.
After 15 minutes a message prompts you to re-open the drawer and re-screw the
cap to waste bottle 1, close the drawer when completed and click ‘OK’.
When the run is complete, unload the plate and the reagent rack and replace the
de-ionized water with the appropriate wash buffers.
2. Decontaminate the sample and reagent racks, plate carrier and tip ejection slide.
3. Decontaminate the system liquid container

Empty the system liquid container.

Empty the container and rinse thoroughly, twice with tap water and once with
de-ionized water.

Inspect the filter (attached to the cap) to see if damaged or in need of replacing.
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Section: Serology Manual


Refill the container with freshly prepared System Liquid.
Preparation of System Liquid: 2 ml of Tween 20 to 10L of de-ionized water.
4. Clean the washer buffer bottles only and NOT the caps & sensor devices.
5. Backup System Files
 Click ‘Backup’ button found at the upper tool bar.
 The System Backup dialog box will open up.
 Click ‘Backup System Files’
 Once completed, click ‘Close’ from the System Backup dialog box.
X.
Quality Control Procedures
1. Calculate the mean absorbance of the Cut-Off Control (Cut-Off X): Sum of the O.D values for
the two Cut-Off controls divided by 2.
The O.D of each Cut-Off control must be ≥0.3000 and ≤0.8000 to be considered valid.
2. Calculate the Negative Control Index by dividing the O.D of the Negative Control by the mean
absorbance of the Cut-Off Control.
Negative Control Index = O.D Negative Control
Mean Cut-off Control O.D
The index of the Negative Control Serum must be less than 0.40 to be considered valid.
3. Calculate the Positive Control Index by dividing the O.D of the Positive Control by the mean
absorbance of the Cut-Off Control.
Positive Control Index= O.D Positive Control
Mean Cut-off Control O.D
The index of the Positive Control Serum must be greater than 2.00 to be considered valid.
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Section: Serology Manual
XI.
Reporting:
1. The presence or absence of galactomannan antigen in the test sample is determined by the
calculation of an index for each patient sample. To calculate the Index of a sample, divide the
O.D of the patient sample by the mean O.D of the cut-off control.
Patient Serum/BAL Index = Patient Sample O.D.
Mean Cut-off Control O.D
2. Patient serums/BAL with an index < 0.50 is considered to be negative for galactomannan
antigen.
3. Patient serums/BAL with an index ≥ 0.50 is considered to be positive for galactomannan
antigen.
4. For patient serums/BAL O.D.=9.0000 [OD>3.50]
a. calculate the index for OD=3.50 :
3.50
Mean Cut-off Control O.D
b. Report patient’s index > the index of OD=3.50
See Evolis EIA Worksheet for calculations
6. All positive specimens will be heat-treated and repeated x2 on the next run.
7. All repeats have to be recorder in EVOLIS REPEATS WORKLIST, and give the filled-up
worklist to ED
8. An absorbance value of less than 0.000 may indicate a procedure or instrument error and the
result is considered invalid and the specimen should be re-run.
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9. Rules for reporting Index≥0.5
Facility
Index
0.5≤Index≤1.0
Initial Reporting
1. Order 8COM
2. Result 8COM:type initial index value
3. Order 8GAL1 and verify
4. Order 8GAL2 and verify
UHN
Index>1.0
1. 8GAL:Positive
Report index in the comment:
(Index Values: #.##)
*Preliminary testing POSITIVE, to be
repeated.
2. Verify 8GAL result
3. Order 8GAL1 and verify
3. Order 8GAL2 and verify
Non- UHN
XII.
Index ≥0.5
2 of 3 results are positive
8GAL:Positive
Report 3 index in the comment:
(Index Values: #.##/#.##/#.##)
2 of 3 results are Negative
8GAL:Negative
Report 3 index in the comment:
(Index Values: #.##/#.##/#.##)
2 of 3 results are positive
8GAL:Positive
Report 3 index in the comment:
(Index Values: #.##/#.##/#.##)
2 of 3 results are Negative
8GAL:Negative
Report 3 index in the comment:
(Index Values: #.##/#.##/#.##)
2 of 3 results are positive
8GAL:Positive
Report 3 index in the comment:
(Index Values: #.##/#.##/#.##)
2 of 3 results are Negative
8GAL:Negative
Report 3 index in the comment:
(Index Values: #.##/#.##/#.##)
Trouble shooting:
UHN/NON-UHN
XIII.
1.Order 8COM
2.Result 8COM:type initial index value
3.Order 8GAL1 and verify
4.Order 8GAL2 and verify
After repeat in duplicate
No index, but has the
following error:
P_max_high
P_min_low
P_stop_high
P_static_high
P_static_high
P_mean_low
1.Order 8COM
2.Result 8COM:type the
error
3.Order 8GAL1 and verify
Only needs to be repeat
once
Report according the
result!
Reference:
Package insert from Platelia Aspergillus EIA
Revised July 2007
EVOLIS™ Short User Manual software version 1.90, revised June 2008
EVOLIS™ User Manual software version 1.90, revised June 2000
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Infectious Mononucleosis Heterophile Antibodies
I.
Introduction
The MONOSPOT LATEX slide test is a latex particle agglutination test for in vitro qualitative
detection of infectious mononucleosis heterophile antibodies (IgM) in serum or plasma. These
antibodies appear in the sera of 85 to 90% of patients with infectious mononucleosis within 2
to 3 weeks after onset of illness.
II.
Specimen Collection and Processing
5 mL of blood is collected in a serum separator tube and separated by centrifugation. The tube
is refrigerated until testing. Specimens are stored at -200C after testing and discarded after 3
months.
III.
Procedure
i) Reagents:
MONOSPOT LATEX Kit:
Store refrigerated. Allow the reagent to warm up to RT. Mix well before use.
ii) Other Materials:
Supplied with kit:
Test slides
Paddle pipettes
iii) Method:
1. Dispense 1 drop of the latex reagent onto a labelled oval ring of the test card.
2. Add 1 drop (50 L) of patients's serum or control to the same ring.
3. Mix the latex reagent and serum together and spread to cover the entire area of the ring
with the blade end of the paddle pipette.
4. Immediately rotate the card on the serologic rotator at 100 rpm for 3 minutes.
5. Observe for agglutination using a light source to aid in visualization.
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Section: Serology Manual
iv) Interpretation of Results:
IV.
V.
Negative:
No agglutination
Positive:
Any degree of agglutination
Reporting
Positive Report:
"Infectious mononucleosis heterophile antibody: POSITIVE"
Negative Report:
"Infectious mononucleosis heterophile antibody: NEGATIVE"
Quality Control
Negative and positive controls must be included with each run and results and kit lot number
recorded on the tasklist. When opening a new kit, record the lot number in the reagent lot
number binder. Refer to a senior technologist if control results are outside of limits or for any
other problems with running or reporting the assay.
Run external control ( Accurrun 31) with each new lot. Result filed in
Reagent Lot Binder. . If result is negative, inform Charge/senior technologist for review.
CAP provides external proficiency testing.
VI.
References
Manufacturer's package insert: Meridian Diagnostics, Inc., 3471 River Hills Dr., Cincinnati,
Ohio 45244 U.S.A. 1-513-271-3700.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Pneumocystis jiroveci (previously known as P. carinii) DFA TEST
I.
Introduction
The Merifluor-Pneumocystis DFA test is an in vitro test for the direct detection of
Pneumocystis carini cysts and trophozoites in bronchoalveolar lavage (BAL), bronchial wash
(BW); sputum or biopsy specimen.
II.
Collection and Transport
BAL, wash and sputum should be collected using standard procedures. Biopsy specimens e.g.
transbronchial, open lung or others must not be fixed and are transported to the lab on a saline
moistened piece of gauze in a sterile container. Tissue should not be allowed to dry or become
immersed in saline. All specimens should be transported as soon as possible to the laboratory.
PCP testing can be done on the day after receipt except specimens received Friday or the day
before a holiday must be stained and read that day.
III.
Procedure
Reagents
FITC- P. carinii conjugate
Control slides
Distilled water
FA mounting fluid
Sputolysin: diluted 1:10 (i.e. 300 Ul sputolysin 3.0 mL distilled water)
Materials
Vortex
Sterile pipettes
10 - 100 uL Eppendorf pipette
Humidified chamber
Coplin jars
Fluorescent microscope
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Section: Serology Manual
Preparation of Slides
BAL and BW:
1.
Centrifuge the BAL or BW for 10 minutes at 1800 x g.
2.
Remove and discard all but 0.5 mL of the supernatant. Thoroughly resuspend the pellet
in the remaining 0.5 mL of fluid.
3.
Make a thin smear twice the size of a cytospin spot and allow to air dry.
4.
Fix in acetone for 5 minutes in a coplin jar, then air dry.
5.
Slide must be stained within 8 hours or freeze at -200C.
Sputum - See Sputolysin Procedure
1.
Combine equal volumes (3 mL each) of sputum and diluted sputolysin. Vortex
mixture.
2.
Incubate for 3 minutes at 350C.
3.
Vortex the mixture briefly and add an equal volume of PBS and entrifuge at 1300 x g
for 5 minutes.
4.
Remove the supernatant, leaving 0.5 mL to resuspend the pellet.
5.
Make a smear twice the size of a cytospin spot. Allow to air dry.
6.
Fix in acetone for 5 minutes in a coplin jar, then air dry.
7.
Slide must be stained within 8 hours or freeze at -200C.
Biopsy Specimen
1.
Prepare a freshly cut surface on a fragment of tissue.
2.
Touch the cut surface to a FA slide. Make several non-overlapping imprints within the
well, avoiding smearing using several cuts.
3.
While imprints are still moist on the slide, fix by adding 1 - 2 drops of acetone and
allow to air dry.
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Section: Serology Manual
4.
Slide must be stained within 8 hours or freeze at -200C.
Staining - DFA
1.
Cover the smear with 30 uL of P. carinii FITC-conjugate antibody.
2.
Incubate in a humidified chamber for 30 minutes at 360C.
3.
Wash slide twice with distilled water for 2 minutes in a coplin jar.
4.
Allow the slide to dry.
5.
Mount using coverslip and mounting fluid.
6.
Read with fluorescence microscope with the FITC / Evans Blue filter and 40x
objective.
Interpretation of Results
POSITIVE:
Any specimen which contains two typical cysts exhibiting apple-green
fluorescence of characteristic morphology. Generally cysts, 5 - 8 um diameter,
are found together with trophozoites in clusters. Clusters can be variable in size
and may appear with or without "honeycomb" like structure. Some cysts
fluoresce evenly throughout their structure whereas other cysts may fluoresce
mainly on their periphery and produce a "honeycomb" appearance within the
clusters.
NEGATIVE: Red fluorescence without any characteristic apple-green fluorescence as
described above.
IV.
Reporting
POSITIVE:
"Pneumocystis jiroveci (previously known as P. carinii) positive by
immunofluorescence".
NEGATIVE: "Pneumocystis (previously known as P. carinii) negative by
immunofluorescence".
Telephone all positive results and document.
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Microbiology Department
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Section: Serology Manual
V.
Quality Controls
Positive and negative control slides should be stained each time the staining procedure is
performed. Refer to a senior technologist if controls do not work or for any other problems
with staining, reading or reporting results.
External QC (slides from a source other than the reagent supplier or the daily QC) should be
done on new reagent lots and if the batch (daily) QC fails.
Check Calcoflour stain result in the LIS for concordance and notify the Mycology section as
well as Senior/Charge if their result is different. Appropriate actions should be taken to
reconcile the difference.
VI.
Reference
1.
Merifluor Pneumocystis, Meridian Diagnostics, Inc. 3471 River Hills Drive, Cincinnati,
Ohio, 45244. Tel. 513-271-3700.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Syphilis Screening
I.
Introduction
The Rapid Plasma Reagin (RPR) Card test is a macroscopic non-treponemal flocculation test
used to detect reagin antibodies.
II.
Specimen Collection and Processing
Blood is collected (5 mL for adult and 1 mL for neonate) in a serum separator tube and
separated by centrifugation. The serum is removed to a tube and refrigerated until testing.
Specimens are stored in the refrigerator for 3 months after testing. A request for VDRL on
spinal fluid (CSF) or neonate blood will be sent to PHL for testing.
Note: The RPR assay must be used for syphilis testing on cadaveric donor specimens.
III.
Procedure
i)
Reagents:
RPR reagent kit (Pulse Scientific Inc.)
ii)
Other Materials:
3 mL dropper bottle
Dispensing needle (17 L/drop)
RPR test card
0.05 mL disposable stirrer pipettes
Serological rotator at 100 rpm
dH2O
iii)
Precaution:
Refrigerate reagents until required. Warm to RT and mix well before use. To ensure
stability, return the antigen suspension to the original glass bottle after testing. The
dispenser and needle assembly must be thoroughly washed in dH2O and air dried after
use.
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Microbiology Department
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Section: Serology Manual
iv)
Needle Accuracy Check - When New Kit Opened:
This procedure is performed to check the needle delivering antigen each time before
testing. Using a pipette, deliver 0.5 mL antigen to the dropper bottle. Attach the needle
and, holding in a vertical position, count the number of drops delivered in 0.5 mL. The
needle is considered satisfactory if 30  1 drops are obtained. If the needle is
unsatisfactory, repeat the check. Record the lot number of the newly opened kit in the
reagent lot number binder.
v)
Method:
1.
Using the stirrer pipette held vertically, dispense one drop (50 L) of serum onto a
circle on the test card. Use a fresh stirrer pipette for each sample. Repeat with the
control sera.
2.
Using the flat end of the stirrer pipette spread the sample over the entire area of the test
circle.
3.
Attach the needle to the dropper bottle. Mix the carbon antigen reagent well. Squeeze
the dropper bottle and withdraw sufficient reagent into the bottle. Discard the first few
drops into the reagent stock bottle and then dispense 1 drop into each circle in a vertical
position. Do not mix the sample and the antigen. Rotate the card at 100 rpm for 8
minutes.
4.
Observe for agglutination by two technologists independently.
vi)
Interpretation of Results:
Positive Result:
Any agglutination. Repeat test ---- see senior technologist for any
discrepant results. Send all positive sera to PHL for VDRL and
confirmatory tests. Write on PHL requisition: "RPR positive, please
do confirmatory test"; DO NOT mark prenatal box for serum from
prenatal patients.
Negative Result: No agglutination.
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Microbiology Department
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Section: Serology Manual
IV.
V.
Reporting
Positive Result:
Enter in LIS as "TO PHL". VDRL send-out test is ordered reflexively.
Send to PHL next day.
Negative Result:
Negative
Quality Control
Strongly reactive, weakly reactive and non-reactive control sera are included in each run. If
controls are not working or the antigen is not falling cleanly from the needle, perform a needle
check as outlined in the method.
Record control results and kit lot number on the task list. Run external control (Accurun 156)
with each new lot. When opening a new kit, record the lot number, needle check and external
control results in the reagent lot binder.
Refer to a senior technologist if control results are outside of limits or for other problems with
running or reporting the assay.
CAP provides external proficiency testing.
VI.
Reference
Manufacturer's package inserts (RPR Card Test, Pulse Scientific Inc., 18-5100 South Service
Road, Burlington, ON L7L 5H4 (905) 333-8188).
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Varicella-Zoster Virus IgG
I.
Introduction
Varicella-Zoster IgG assays is used for evaluating patient's immune status to Varicella-Zoster
viruses infection. The VIDAS is an enzyme-linked fluorescent immunoassay (ELFA) utilizing a
virus coated Solid-Phase-Receptacle (SPR) to which antibody in serum binds. Anti-Human IgG
conjugated with Alkaline Phosphatase reacts with substrate, 4-Methylumbelliferyl Phosphate to
form a fluorescent product. All necessary reagents and test serum are contained in the VZG
reagent strips.
II.
Specimen Collection and Processing
Blood (5 mL) is collected in a serum separator tube and separated by centrifugation. The serum is
removed to a vial and refrigerated until testing. Specimens are stored at -20oC after testing.
III.
Procedure
Reagents
VIDAS Varicella-Zoster IgG test kit:
VZG Reagent Strips
VZG SPRs
Standard
Positive Control
Negative Control
Other materials:
Pipettor 100 uL
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Method
1.
Bring test kit and serum samples to room temperature. Check that lot number of kit
matches lot currently in use (as posted on VIDAS instrument). If lot number does not
match, ensure that all kits/test strips for the posted lot number have been used.
Enter new lot data by inserting bar code card found in kit into tray, load tray into Section
‘A’. Press ‘Master Lot Menu’,’ Read Master Lot’ and section ‘A’. The machine will move
the tray and read the card. At the end, press ‘Master Lot Menu’, use ↓ to ‘List Master Lot’.
Press that button, and also ‘VZG’, will show three lots #. Check that one of these includes
the new lot.
Post card of new lot currently in use on VIDAS along with the date.
2.
Label MSG/VZG strips as follows:
s (Standard)
s (Standard)
C1 (Positive Control)
C2 (Negative Control)
5
6 etc. up to 30
3.
Pipette 100 uL of Standard, Control or serum into
the specimen well of the corresponding VZG strips.
Check for adequate sample level and remove any bubbles.
4.
At VIDAS instrument, start at Main Menu.
To program a run with Standards( Alarm will alert the expiration of
standards):
a. Load strips(containing 100 ul of each standards, controls, or samples) and tips into
Mini Vidas.
b. Press ‘Status Screen”- will show ‘A’ and ‘B’ available.
c. Press ‘A’.
d. Section ‘A’ appears with 1,2,3,4,5,6.
e. Press’1’(Position 1), then press ‘S’ for Standard.
f. Standard number (1-4) appears, press ‘1’,will show ‘S1’,’Enter’.
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Policy & Procedure Manual
Section: Serology Manual
g. Press ‘2’(position 2), then press ‘S’ for Standard.
h. Standard number (1-4) appears, press ‘1’ (not 2) ,will show ‘S1’,’Enter’.
i. .Press ‘3’ (position 3), then press ‘C’ for Control.
j. Control number (1-4) will appear, press ‘1’, will show ‘C1’,’Enter’.
k. Press ‘4’ (position 4), then press ‘C’ for Control.
l. Control number (1-4) will appear, press ‘2’, will show ‘C2’,’Enter’.
m. Press ‘5’ (position 5), then press ‘Sample ID’.
n. Use arrow to move cursor to ‘D’, press button connected to that line (Last
button).Then press # on the keyboard to enter all the numbers.’ Enter’.
o. Press ‘6 (position 6), then press ‘Sample ID’.
p. Use arrow to move cursor to ‘D’, press button connected to that line (Last
button).Then press # on the keyboard to enter all the numbers.’ Enter’.
q. Press ‘Start’. Once check has been completed and ‘OK’, green light will stay on,
and screen will show the time the testing will be finished.
r. Press ’B’ for next module.
s. Press ‘1 (position 1), then press ‘Sample ID’.
t. Use arrow to move cursor to ‘D’, press button connected to that line (Last
button).Then press # on the keyboard to enter all the numbers.’ Enter’.
u. Do the same for the rest of the positions.
v. Press ‘Start’. Once check has been completed and ‘OK’, green light will stay on,
and screen will show the time the testing will be finished.
w. Once the testing is finished,’ Unload’ will appear. Unload strips and tips. Check
strips that show ‘NEGATIVE’ for inoculums.
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Policy & Procedure Manual
Section: Serology Manual
To program a run with without Standard:
a. Load strips (containing 100 ul of each controls, or samples) and tips into Mini Vidas.
b. Press ‘Status Screen”- will show ‘A’ and ‘B’ available.
c. Press ‘A’.
d. Section ‘A’ appears with 1, 2, 3, 4, 5, 6.
e. Press ‘1’(position 1), then press ‘C’ for Control.
f. Control number (1-4) will appear, press ‘1’, will show ‘C1’,’Enter’.
g. Press ‘2’ (position 2), then press ‘C’ for Control.
h. Control number (1-4) will appear, press ‘2’, will show ‘C2’,’Enter’.
i. Press ‘3’ (position 3), then press ‘Sample ID’.
j. Use arrow to move cursor to ‘D’, press button connected to that line (Last button).
Then press # on the keyboard to enter all the numbers.’ Enter’.
k. Do the same for the rest of the positions.
l. Press ‘Start’. Once check has been completed and ‘OK’, green light will stay on, and
screen will show the time the testing will be finished.
m. Press ’B’ for next module.
n. Press ‘1 (position 1), then press ‘Sample ID’.
o. Use arrow to move cursor to ‘D’, press button connected to that line (Last
button).Then press # on the keyboard to enter all the numbers.’ Enter’.
p. Do the same for the rest of the positions.
q. Press ‘Start’. Once check has been completed and ‘OK’, green light will stay on, and
screen will show the time the testing will be finished.
r. Once the testing is finished,’ Unload’ will appear. Unload strips and tips. Check strips
that show ‘NEGATIVE’ for inoculums.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Interpretation of Results
Specimens with test values greater than 0.9 (MEA/VZ) are considered positive. Test values
ranging from 0.6-0.9 are equivocal.
Samples with test values less than 0.6 (MEA/VZ) are considered negative.
IV.
V.
Reporting
Positive:
Varicella-Zoster antibody:
Positive
Equivocal:
Varicella-Zoster antibody:
Equivocal
Negative:
Varicella-Zoster antibody:
Negative
Quality Control
Standard: RFV must be greater than or equal to RFV range posted on VIDAS instrument.
Positive and Negative Control: Test Values must be within ranges posted on VIDAS.
Quality Control ranges posted on VIDAS may change from lot to lot, therefore it is essential that
the lot number of the test kit in use corresponds to that of the posted values.
Refer to a senior technologist if control results are outside of limits or for any other problems with
running or reporting the assay.
Run external control (pooled positive sera) with each new lot. Results filed in Reagent Lot
Binder. If result is negative, the run is invalid. Inform Charge/senior technologist, and repeat
testing.
CAP provides external proficiency testing.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Monthly:
Run QCV :
1. Press ‘Status Screen’.
2. Press section‘A’.
3. Press position ‘1’.
4. Press ‘Assay’ and ‘Select Assay’.
5. Press ‘QCV’.
6. Press ‘Enter’.
7. Press position ‘2’, will show’QCV’ on screen, ‘Enter’.
8. Repeat step # 7 for positon 3-6.
9. Load 6 strips and tips from ‘QCV kit’.
10. Press ‘Start’.
11. Repeat step 1 to 9 for Section ‘B’.
12. Check values: TV1 >= value stated on box
R3 >= 4100 RFU
13. Staple print out sheets and file in MiniVidas binder, initial ‘Monthly QC’.
Clean Lens:
1. Open the left side of section A where tips are loaded all the way down.
2. Use device provided from Vidas to get rid of any dust on the lens by pumping air onto the
lens.
VI.
Reference
Manufacturer's Package Insert.
MINI-VIDAS System Operational Manual.
bioMerieux-Vitek, Inc.
Missouri, USA 64042-2395
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Appendix I - Serology Test Schedule
EBV VCA IgG ............................................................................................................................ Daily
EBV EBNA-1 ........................................................................................................................... Weekly
Galactomanan ....... Set up Tuesday & Thursday evening; resulted Wednesday & Thursday morning
HBsAg ........................................................................................................................................... daily
HBsAg confirmation ........................................................................................................ when needed
HBsAb ........................................................................................................................................... daily
HBcAb-Total ................................................................................................................................. daily
HBcAb-IgM ................................................................................................................................... daily
HAV-IgG ....................................................................................................................................... daily
HAV-IgM ...................................................................................................................................... daily
HBeAg / HBeAb .......................................................................................................................... .daily
Monospot IM heterophile Ab ........................................................................................................ daily
Rubella Ab ..................................................................................................................................... daily
Varicella-Zoster Ab .................................................................................................. STAT or Tuesday
RPR for Syphilis ............................................................................................................. STAT or daily
HCV Ab ......................................................................................................................................... daily
CMV IgG Ab ................................................................................................................................ daily
CMV Total Ab(Immucor) ............................................................................................................. daily
HIV Ab .......................................................................................................................................... daily
HTLV Ab....................................................................................................................................... daily
Syphilis TP AB (cmia) .................................................................................................................. daily
*
Stat testing may be required where clinically justified.
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Policy # MI/SER/v48
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Appendix II - List of Tests Referred Out to Other Laboratories
TEST
REQUISITION
PHL General
DESTINATION
1.
Amoebic serology
Serology PHL
2.
Aspergillus precipitins
PHL General
Serology PHL
3.
Avian precipitins
HICL label/requisition
Specify bird in question
Hospital In-Comm Lab
1 William Morgan Dr.
Toronto, Ontario
M4H 1N6
Tel. (416) 422-3000
4.
Chlamydial culture*
PHL General
Virology PHL
5.
Diphtheria antitoxin
toxin
Reference Bacteriology
6.
Fungal antibodies
PHL General
Special
Bacteriology
PHL
Serology PHL
7.
Malaria
PHL General
Parasitology PHL
8.
Mycoplasma PCR
PHL General
Bacteriology PHL
9.
Genital Mycoplasma*/
Ureaplasma culture*
PHL General
Mycoplasma PHL
10.
Legionella (tissue)
Legionella urine antigen
PHL General
PHL General
Bacteriology PHL
Serology
11.
Lyme disease Ab
PHL General
Serology PHL
12.
PARASITIC SEROLOGY
PHL General
Serology PHL
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Section: Serology Manual
TEST
13.
REQUISITION
DESTINATION
PARASITIC SEROLOGY cont’d
Only by special request from Topical Diseases' physicians:
Cystercosis
CDC 50.34 Rev.09/2002
Echinococcus
(must be completed by
Leishmania
ref .physician)
Schistosoma
Strongyloides
Toxocara
Trichinella
Trypanosoma
Miscellaneous
Filaria
Center for Disease
Control and prevention
1600 Clifton Road,N.E.
Atlanta, Georgia
U.S.A. 30333
Control and prevention
1600 Clifton Road,N.E
Atlanta, Georgia
U.S.A. 30333
NIH Filaria form
(must be completed by
ref.physician)
Laboratory of ParasiticDiseases
National Institute of Allergy &
Infectious Diseases
National Institutes of Health
Building 4,Rm 126
Bethesda,Maryland
U.S.A. 20892
Special Bact. PHL
14.
Tetanus antitoxin titre
Reference Bacteriology
15.
Toxoplasma IgG Total
Toxoplasma IgM
PHL form 97-44(08/99)
Serology PHL
16.
VDRL (CSF)
PHL General
Serology PHL
17.
Electron microscopy
PHL General
Virology PHL
Tel. (416) 422-3000
18.
Parvovirus Ab IgG, IgM
PHL General
Serology PHL
19.
Histoplasma Antigen
in Urine
20.
Multi-Resistant Organism for
MiraVista Diagnostics
4444 Decatur Blvd.,
Suite 300
Indianapolis, IN 46241
1-866-Mira Vista (647-2847)
Phone: 317-856-2681
Special Research Microbiology
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Section: Serology Manual
Multiple Combination
Bactericidal Test
Room 3043B
Children’s Hospital of Eastern
Ontario,
401 Smyth Rd. Ottawa, ON K1H 8L1
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Section: Serology Manual
Appendix III - Daily Work-Up for Architect Bench
1. ‘Log on” in Architect
2. Run daily/Weekly Maintenance in the morning, also run all the controls.
- Don’t forget to replace and clean the filter under the architect.
- Do not need to put septum in 0.5% Javex bottle used for Daily Maintenance, empty content
when procedure done.
3. Back up weekly:
a. Files to Architect:
- f:drive-‘System’, ‘Utilities’, ‘F4-create back up’ and ‘Done’.
b. QC and Test results to CD
- ‘Results’,‘Stored Results’,‘Select All’,‘Archive’, must remove ‘√’
- delete records after archive before next step.
- Insert CD into CD Drive. Follow instruction on screen. When finished press ‘Done’.
Remove CD from CD Drive. Label archive date on front of CD cover.
4. Do architect inventory every Friday afternoon.
5. Document Laminar flow hood (MIBCT4) cleaning in 'mic'-go 'RESULT'-'Worklist”- Virology
Architect.
6. Load specimens. Do in-house specimens first, then do the GW CMV Avidity specimens. GW
specimens can be run throughout the evening and night shift.
7. Post and verify all QC in the LIS.
'Lab'.
8-Interface Menu
i. -Architect-enter
ii. 'Open' is highlighted-enter
iii. Choose Result File Date that you want to post QC-enter
iv. Press 'L' for 'Look'-F12
v. QCs are designated with a 'O' before sequential number. You must go into each
QC and post result by pressing 'SHIFT & +' at the same time. Pop up will tell you
the result was posted.
vi. Press F5 twice to go to next QC result, continue until all QC result are posted.
8. If a new Control lot is opened, must update in Architect-follow ' To enter New Control Lot #'
procedure.
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
9. QC rule violation: a prop up screen will alert us.
a. 1-3s: repeat with new aliquot-if still fail- do Calibration.
b. 1-2sd is a warning-check yesterday's QC printout sheet,and see if it was the same
violationc. 1-2sd is OK, but 2 -2sd in two days is a rule violation-do calibration.
d. If 2 controls are 1-2sd, do calibration.
10. Architect must be on 'running' mode overnight, so that all the solutions will be flushed regularly.
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Section: Serology Manual
Appendix IV - Entering and Verifying Serology Refer-Out Results
Refer-out Reporting Bench Workflow and Notes:
Bench Workflow:
1. Check the fax machine at the secretary’s desk. If the secretary is not in, separate the received PHL
reports. Separate out all the serology reports from the rest and keep any abnormal positive and
results in a separate pile as well. Preliminary reports are NOT ENTERED unless they are abnormal
positive results and can be filed immediately in the Iron Mountain box under the secretary’s desk.
Also, check the fax machine in Virology beside John’s office for reports. Replenish paper if a fax
machine is out.
2. Phone, enter and verify all significant positive results first. These tests include 9VD (ONLY if
RPR is REACTIVE, and not previously positive), 9TSC/9HIV, 9HTLV, 9PARM). Positive reports
get filed in the Positive PHL report binder in the Virology Lab (shelf beside the sink). Reports not
from PHL (NML, CDC etc.) get filed in the black binder on the cabinet behind Lily.
3. Enter and/or verify any Amended reports or problem reports solved but awaiting to be finalized.
4. Check pending samples WEEKLY. Use the 9SERO worklist to find pending results. Fax PHL lists
of pending reports and tests to be re-faxed. This is done by creating a document including patient’s
first & last name, HCN, LIS order #, Date of collected and which tests are pending.
5. Proceed to enter and verify all other reports. Report all tests done by PHL, order the tests if not
already ordered. If a final report is received and there are pending tests in the LIS order other than
HTLV and HIV (e.g. Parvo IgM, HSV IgM etc.) call PHL to ensure test was ordered. If the test
was ordered but is not being done by PHL enter as: “Not tested by PHL”. If a report has any
discrepancies regarding patient information, call PHL immediately to verify and refax an amended
report.
6. Tests done on the Architect which were sent to PHL for confirmation (9HCA, 9VD, 9TSC,
9HTLA) order the “9” sendout test codes if not already ordered and enter results under these
codes.
7. Report all titres for tests in LIS EXCEPT HBsAb titres.
8. File all PHL reports by bench side into Iron Mountain boxes with the exception of the significant
positive reports and non PHL reports (e.g. CDC, NML etc.). If a report page contains only
Historical Data, KEEP IT and file it, attach it to the other report pages if you have them.
9. When Flu subtyping is done by NML. Enter the subtype under the Isolate Comment F8 window.
Indicating subtyping is done by NML.
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Section: Serology Manual
NOTES:
1. When notifying PHL to send amended reports, keep the original in the PENDING RESULT
folder. After receiving an Amended Report, match it up with the original report, shred the
original and file the Amended report.
2. When calling PHL, they will only look up 2 reports at a time. Do not wait until there are more
than 2 reports before calling for queries. Call PHL immediately as you come across the reports.
Entering and Verifying Verbal Reports.
Stat results from PHL are called to the laboratory before a faxed report is sent. These results must be
called, entered and verified immediately.
1. Receiving the call:
 Record verbal PHL results on the green “Refer-out Test – PHL Verbal Results Recording
Form” QPCMI17001a sheet.
 Ensure to fill in all sections including the patient’s First and Last name, LIS# and PHL#
and the result. Read back information and results to verify correct records.
2. Enter the results:
 Open order entry. Search the order by entering the LIS number provided. Match the patient
information provided with that in the LIS.
 Click the Result Tab. Enter each result using the options in the keypad. Do NOT free text
results.
 Select “\” to enter canned messages and the PHL (or other site) number. If there are special
notes/interpretations/comments inquire whether they should be added in the canned
message field. DO NOT enter “Verbal Report” in the canned message field.
 Document in the call window that you received a verbal report from PHL and who you
spoke with.
 DO NOT VERIFY AT THIS STAGE.
 Save. If the test was previously verified (e.g. as “sent to PHL”) a pop-up window will
appear warning a modification of verified results. Use this as a double check, and accept
results by clicking “OK”.
3. Verify the result
 With the verbal report still in front of you, go back into order entry to check and verify the
result.
 Double check all the patient information and check them off the report as you do so.
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Policy & Procedure Manual
Section: Serology Manual

Open the results tab. Check results. Open the canned message (click “ \ “) and ensure the
entire message is there, no letters missing or extra letters at the beginning or end of the
comment, that the canned message is not entered twice and ensure the PHL number is
correct - check every number.
 Verify the test result after the result and canned message is checked, by hitting “ [ “ key on
the test
 Initial and date the PHL Report.
4. Calling the result.
 After verifying the result call the result to ward or ordering physician. Provide all the
information including the patient’s MRN, date of collection of sample and result. Make
sure results are read back.
 In order entry, order 8call or 8calo for units. In the call window document the phone call
including the name of the person taking the result.
 File the verbal results recording form in Virology. There is a “PHL Verbal Reports” binder.
Entering and Verifying Serology Refer-Out Results Procedure
Refer-out test results for blood specimens can only be recorded in the LIS using SCC lab module.
When the reports come back from a reference laboratory, the result, reference lab number and
reporting date are entered.
Enter results by PRIORITY:
1. Positive Results
2. Pending Results (problem reports solved but awaiting to be finalized)
3. Prenatal Results
4. Non-Prenatal Results
PROCEDURE:
1. Log on to “SOFTLAB”, open ORDER ENTRY.
2. Search by Order number, ensuring “Open in Edit Mode” is checked, and click Find or press
Enter to launch search.
 If no order number is indicated on the PHL report, look for the order by using the HCN,
MRN or Last name/First name with DOB. If an order is found and has the same collection
date, use this order.
 If no order is found but the patient is in the LIS and Dr. Mazzulli is the provider (e.g.
fertility clinic), create a new order. A new visit can be created with the referring doctor if
necessary.
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Policy & Procedure Manual
Section: Serology Manual
If a report does not have Dr. Mazzulli as the Provider but the report has an LIS order number,
the report can be entered.
 If no patient is found in the LIS and/or Dr. Low is not the provider, write on the report
“patient not found” and forward the report to the sectary for mailing.
3. Match the patient information
 Compare the first and last name, Date of Birth, MRN, HCN. (All information)
 Ensure you chose the correct order when searching with an MRN/HCN etc. by matching
the collection date of the sample in the LIS and the date on the report and the auxiliary
number if provided and the sample from UHN.
 If the patient has a different last name, verify under “Show Linked Patients” in Order Entry
to see if the last name has been changed. If the last name on the report is not present, call
PHL to correct the last name. If the last name is present, accept the report.
Call PHL to verify any other discrepancies and to re-fax an amended report immediately as
you come across these reports. Do not batch them together for later. PHL will fix and refax a maximum of 2 reports per phone call.
 File reports with discrepancies waiting for amended results in the ‘Pending Results’ folder.
4. Enter results
 When entering results, only have the ONE report you are entering in front of you.
 Click the Result Tab after you have matched the patient information. Enter each result
using the options in the keypad. Do NOT free text results. Enter results in the order they
appear on the printed report as to not miss or skip any results (as opposed to test order in
the LIS).
 Select “\” to enter canned messages and the PHL (or other site) number. If there are special
notes/interpretations/comments inquire whether they should be added in the canned
message field. If there are many tests in an order you can copy and paste the PHL #
comment and paste it after the canned messages in each test results you.
 DO NOT VERIFY AT THIS STAGE.
 Save. If the test was previously verified (e.g. as “sent to PHL”) a pop-up window will
appear warning a modification of verified results. Use this as a double check, and accept
results by clicking “OK”.
 Initial and date the report
 Check and Enter reports and put them aside before verifying. After 5 reports have been
checked and entered take the pile and start verifying those 5 results one at a time. Do not
enter a result and verify reports immediately (one by one).
5. Verifying Results
 DO NOT VERIFY ANY RESULTS WIHTOUT THE REPORT INFRONT OF YOU.
 Take the pile of 5 reports just entered, one at a time, check results through order entry by
the order number.
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Policy & Procedure Manual
Section: Serology Manual


Double check all the patient information and check them off the report as you do so.
Open the results tab. Check results in the order appearing on the PHL report. Ensure the
correct result is entered for each test.
 Open the canned message (click “ \ “) for EACH test and ensure the entire message is
there, no letters missing or extra letters at the beginning or end of the comment, that the
canned message is not entered twice and ensure the PHL number is correct - check every
number.
 Verify individual test result after the results and canned message is checked one by one, by
hitting “ [ “ key on EACH test as checked.
 Initial the PHL Report and file in the box provided. All positives should already have a call
made. Double check the positive results have been called before verifying these results. .
File positive results in the appropriate section in the positive results binder.
6. Pending results
 Check pending list weekly at a minimum.
 Log on to SOFTLAB, double clicking Resulting Worklist icon. Fill out the screen as
follows:
- Under “Template” enter: 9SERO
- Status as Pend + Nonver.
- Change order# range to include several months
- Check: Received only, hit OK to search.
 Pending results must be faxed to PHL with sample information to get the report re-faxed.
DO NOT ENTER OR VERIFY ANY PENDING RESULTS IN THIS WORKLIST.
 Orders that have been received and sent to PHL with no results received need to be faxed to
PHL so they may re-fax us the results back.
 If there are old orders with some results entered but some tests still pending PHL can be
faxed the same way as above but only include tests that are pending.
 If there are orders that have been entered but not verified DO NOT VERIFY. The
information from these orders must be sent to PHL to get a re-fax of results as well before
verification can occur.
 In these cases, send a fax to PHL with the following information. A table in excel or word
can be created to include all the pending orders. Send the fax with a cover page to: 416235-6552.
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Policy & Procedure Manual
Section: Serology Manual
Last
Name
First
Name
DOB
HCN
(if no HCN provide
mrn)
LIS order
#
Date of
collection
Missing
tests
1.
2.
3.


Keep a copy of faxed results in the pending results folder and follow up on these reports.
If an order has a pending test (e.g Parvo IgM/HSV IgM) that was sent to PHL but not done
confirm by telephone if it is being done. Result as appropriate. If the test is not being done,
result the test as “Not tested by PHL”
PHL can be called for inquiries or re-faxes at their customer service phone number, but will only deal with a
max or 2
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Appendix V - Autoverification Process
I.
Introduction
To document the autoverification process.
Autoverification is the process by which the computer performs the initial verification of test
results. Any value, that falls outside of the defined criteria, must be assessed by a technologist
before release of results.
II.
Procedure
1. The laboratory has a policy signed by the laboratory director approving the autoverification
procedure.
2. The results of autoverification is thoroughly tested, appropriately documented and signed by
the section head/designee before implementation.
3. If changes are made to the autoverification rules initially chosen and documented, the process
is reverified as to its accuracy.
4. The autoverification process is checked yearly.
AUTOVERIFICATION FOR THE ARCHITECT INSTRUMENT
POLICY:
The Architect instrument performs the following tests for the Serology department:
f. Hepatitis B Surface Antigen
g. Hepatitis B Surface Antibody
h. Hepatitis B Core Antibody
i. Hepatitis A IgM Antibody
j. Hepatitis B Core IgM Antibody
k. Hepatitis Be Antigen
l. Hepatitis Be Antibody
m. Hepatitis C Antibody
n. Rubella Antibody
o. EBV VCA IgG
p. EBV EBNA-1
q. Cytomegalovirus Antibody: CMV IgG, CMV IgGR ,CMV IgM and CMV Avidity
r. Transplant Screen
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Policy & Procedure Manual
Section: Serology Manual
Autoverification will occur as follows:
TEST NAME
SOFT
RESULT
TEST
CODE
Hep B Surface Ag 8HAG
NEGATIVE
TRANSLATION ACTION
Negative
Autoposted
Autoverified
Hep B Surface Ag
8HAG
REACTIVE
Review?
NOT Autoposted
NOT
Autoverified
Hep B Surface Ab
8HAB
REACTIVE
POSITIVE
Hep B Surface Ab
8HAB
NEGATIVE
Negative
Hep B Surface Ab
8HAB
GZ-NEGATIVE
Neg
Autoposted
Autoverified
Autoposted
Autoverified
Not Autoposted
Not Autoverified
Hep B Core Ab
8HBC
REACTIVE
REACTIVE
Hep B Core Ab
8HBC
NEGATIVE
Negative
Hep A IgM Ab
8HAV
REACTIVE
REACTIVE
Hep B Core IgM
Ab
Rubella
8HBCM
REACTIVE
POSITIVE
8RUB
NEGATIVE
Negative
Rubella
8RUB
GRAYZONE
Negative
Not Autoposted
Not Autoverified
Autoposted
Autoverified
Not Autoposted
Not Autoverified
Not Autoposted
Not Autoverified
Autoposted
Autoverified
Autoposted
Autoverified
REFLEX
TESTS
8HBC
Hep B
Core Ab
8HBC2
8HBC2
8RUB2
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
TEST NAME
RESULT
EBV VCA IgG
SOFT
TEST
CODE
8EBV
TRANSLATION ACTION
EBV VCA IgG
8EBV
REACTIVE
REACTIVE
EBV VCA IgG
8EBV
EQUIVOCAL
EQUIVOCAL
EBV EBNA-1
8EBNA
NONREACTIVE NONREACTIVE
EBV EBNA-1
8EBNA
REACTIVE
REACTIVE
EBV EBNA-1
8EBNA
EQUIVOCAL
EQUIVOCAL
CMV IgG
CMV IgGR
CMV IgG
CMV IgGR
CMV IgG
8CMS
8CMG
8CMS
8CMG
8CMS
8CMG
NONREACTIVE NONREACTIVE
CMV IgM
8CMM
CMV Avidityy
8CMVA
NONREACTIVE NONREACTIVE
REACTIVE
REACTIVE
GRAYZONE
6.00-15.00
AU/mL
(low Level)
NONREACTIVE Negative
REACTIVE
Positive
<50 %
Low Avidity
>60%
High Avidity
REFLEX
TESTS
Autoposted
Autoverified
Autoposted
Not Autoverified
Autoposted
Not Autoverified
Autoposted
Autoverified
Autoposted
Not Autoverified
Autoposted
Not Autoverified
Autoposted
Autoverified
Autoposted
Autoverified
Autoposted
Autoverified
Autoposted
Autoverified
Autoposted
Autoverified
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Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Appendix VI - Shipment of Samples to HSC
1. Fill out a HSC requisition. (Molecular tests require a colour coded UHN/MSH refer out
Requisition to HSC Molecular Microbiology, Lab no. and tech initials)
2. Put specimen and requisition in biohazard bag, and then in a brown paper bag.
3. Put ‘Hospital for Sick Children, Microbiology Receiving,3rd Floor Atrium, Rm3676’
sticker on brown bag.
4. Put labeled brown bag into blue specimen container, and send to ‘TG specimen
management’.
5. Enter in LIS as ‘specimen send to HSC’ and finalize.
6. Also enter in serology send out binder.
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Section: Serology Manual
Appendix VII - Looking Up Previous Hepatitis Results in EPR
1. Log on ‘EPR’.
2. Enter’ user ID’ & ‘Password’.
s. Click on ‘All UHN Patients’.
t. Enter ‘MRN # in ‘Patient ID’, press ‘Enter’.
u. Click on ‘any visit’, then click on ‘Goto Selected visit’.
v. Click on ‘Chart Review’, ‘Continue?’,Click on’ (y) yes’.
w. Click on ‘Hepatitis Profile’, click on ‘OK’.
x. All previous Hepatitis test results will be displayed, e.g. HBsAg, HBsAb, HBcAb IgM,
HBeAg, HBeAb, HC Ab, and HAAb IgM.
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Section: Serology Manual
Appendix VIII - Printing of Pending List
1. Log on ‘Lab’.
1. Enter ‘ID’ &’Password’.
2. ‘3’-Results
3. ‘View/Enter Results by Sel Tests’.
4. Select tests by ‘Template’,’Enter’.
5. Enter ‘8SERO’ under ‘Template’, ‘Status- pend +nonver’.
6. From order( enter last month’s lab #) to’ leave it blank’.’F12’.
7. ‘F9’ to print. Choose either ‘TC2RVIR’ or ‘TC3R MIC’ printer to print.
8. Look up each record, and find out why the results are still pending.
UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT
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Policy # MI/SER/v48
Page 88 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Appendix IX – Donor Serology and Molecular Tests List
Donor Serology and Molecular Testing at Mount Sinai Hospital
Donor Serology and Molecular Testing at Mount Sinai Hospital for TGLN
Donor Serology and Molecular Testing for at MSH Living Donors
UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT
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Policy # MI/SER/v48
Page 89 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Appendix X – Movement Throughout Containment Zones
Policy:
All specimens and potentially infectious materials transported throughout the hospital must be done in
accordance with the policy for Transportation of Dangerous Goods and Material.
Purpose:
This policy ensures the safe transportation of specimens and dangerous materials to minimize
potential biohazard and safety risk to the public and to the staff handling the materials.
Responsibility:
Management and employees
Procedure:
When transporting specimens and potentially infectious materials, they must be appropriately
contained.
To pick up or drop off serology specimens, follow the steps outlined.
1. Whether picking up or dropping off samples, retrieve the designated transportation cart located
beside the technicians. This cart is CLEAN and should be wiped with alcohol before leaving
the laboratory.
2. Ensure the cart is stocked with all necessary supplies including: Virox wipes, lab coat, paper
towel, biohazard garbage bags and gloves of various sizes.
3. The designated grey box located beside the architect will be used to transport the specimens.
While in transit, the lid should be kept on at all times.
4. Capped specimens should be placed in plastic racks and these racks can be secured into the
large grey box for transport. Secure the lid onto the grey box and place onto the clean trolley.
5. After removing lab wear and washing hands, proceed outside the laboratory. Do no use patient
elevators to transport samples.
6. Do not manipulate the box or samples in any way while in transit.
Should a spill occur, refer to the materials on the cart of clean up. Discard waste in biohazard
garbage bag provided, secure in box and bring back to the laboratory for disposal.
7. At the outside location, using gloves, transfer specimens from the grey box to the designated
location. Discard gloves after use and wash hands.
8. Upon returning to the laboratory, remove specimens and return the cart and grey box to their
locations and refill any materials used.
UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT
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Policy # MI/SER/v48
Page 90 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
To drop off virology dangerous chemical waste, follow the steps outlined.
1. Waste must be transported to the MSH Autopsy Suite on the 6th floor, room 6-311-4. A chemical
waste disposal form must be filled out and emailed to Salim before the waste is transported and
delivered. The waste should be brought down only at 3:30pm. See Lilly or Linda for Salim’s
email.
2. When transporting waste throughout containment zones, retrieve the designated transportation
cart located beside the technicians. This cart is CLEAN and should be wiped with alcohol
before leaving the laboratory.
3. Ensure the cart is stocked with all necessary supplies including: Absorbant pads, Virox wipes,
lab coat, paper towel, biohazard garbage bags and gloves of various sizes.
4. Ensure the chemical waste containers lids are properly secured and place containers on
designated cart.
After removing lab wear and washing hands, proceed outside the laboratory. Do no use patient
elevators to transport samples.
5. Do not manipulate the containers in any way while in transit.
Should a spill occur, refer to the materials on the cart of clean up. Discard waste in biohazard
garbage bag provided, secure in box and bring back to the laboratory for disposal.
Chemical spill kits are available if a spill occurs inside the 6th floor laboratories.
6. At the outside location, using gloves, transfer containers to the designated location. Discard
gloves after use and wash hands.
7. Upon returning to the laboratory, clean and return the cart to its location and refill any
materials used.
UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT
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Policy # MI/SER/v48
Page 91 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Record of Edited Revisions
Manual Section Name: Serology
Page Number / Item
Date of Revision
Annual Review
Molecular Testing - HBV DNA-Reporting Added Para.
AxSym System-Reporting Results HBsAg
AxSym - CMV IgG Antibody (x)
AxSym – Quality Control External Controls
AxSym - Added Failed QC
AxSym HbsAg Surface Antigen - Pt. Samples
Appendix V (f) Added Steps
HCV-RNA PCR Reporting – Positives
Annual Review
Page 6 – Interpretation of Results – OD changed for
Positive and Interdeterminate.
Page 6, 15 – Run external control – include QC and
instrument problems
Page 8 – re-centrifuge cloudy, previously frozen,
reconstituted samples.
Page 8 - Refer to Abbott Operation Manual vol. 1&2 for
specific maintenance procedures
Page 13, 14 – report to MOH added
Page 13, 14 – centrifuge before repeating
Page 16, file log and external control out of range
Page 48 – store VDRL samples for 3 months after testing
Page 51 – 56 VZV Vidas revised
Page 57 – WNV IgG not currently in use
Page 61 – WNV IgM not currently in use
Page 67 - Molecular Testing - Chlamydia Trachomatis &
Neisseria gonorrhoeae
Page 67 – urine but not more than 60 mL added
Page 68 – specimen not lysed…added
Page 68 – tubes may be blotted
Page 70 – handling samples after lysing
Page 71,72 Procedure change
Page 72, interpretation of result - change MOTA score
Page 73, reporting – indeterminate
Page 76 – do not vortex working master mix
Page 76 – specimen dilution protocol
Page 77 – 80 procedure and reporting changed
May 12, 2003
October 10, 2003
October 28, 2003
October 28, 2003
October 28, 2003
October 28, 2003
January 22, 2004
January 15, 2004
April 02, 2004
May 26, 2004
Signature of
Approval
May 20, 2005
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
May 20, 2005
Dr. T. Mazzulli
May 20, 2005
Dr. T. Mazzulli
May 20, 2005
Dr. T. Mazzulli
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT
NOTE: This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked
against the document (titled as above) on the server prior to use.
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Policy # MI/SER/v48
Page 92 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Page Number / Item
Date of Revision
Page 81 – QC procedure changed
Page 93 – procedure changed
Page 86 – 88, instrument instructions
Page 90 – WNV RT-PCR
Page 92 – lysis buffer
Page 93 – General Precaution section revised
Page 94-100 – procedure revised
Page 101 – schedule revised
Page 105 – shipping to St. Joseph’s
Page 121 – shipping to HSC
Annual Review
Page 128 – Updated decontamination procedure
Page 6 – C. difficile toxin indeterminate range changed
Page 13 – HBc IgM reporting guide changed
Page 15 – MV, Rubella reporting
Annual Review
Added links to TGLN Procedures
Annual Review
Added Labour and Delivery STAT HBsAg and HIV
Instruction
Added Immuncor Capture-CMV Assay
Revised Document numbers
Added Ortho ELISA Assays for HBcore, HCV,
HTLVI/II for Donor Testing
Annual Review
Report positive C. difficile toxin as an ISOLATE in the
LIS
Serology Referred Out Test Results Entry Phrases added
Replaced HBsAg, HIV 1/2 HBcAb, HCV Ab, HTLV I/II
Ab donor serology sections
Added Aspergillus Galactomannan Antigen Detection
Assay
Annual Review
Architect System added
C. difficile Toxin EIA edited with Premier kit
Annual Review
Remove C. difficile toxin EIA
Syphillis screen added to Architect System
Modified RPR for Cadaver donors
Updated Axsym procedure
Signature of
Approval
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
May 20, 2005
June 2, 2005
December 29, 2005
December 29, 2005
May 29, 2006
May 29, 2006
March 21, 2007
June 8, 2007
March 19, 2008
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
July 14, 2008
July 14, 2008
July 14, 2008
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
July 14, 2008
September 16, 2008
Dr. T. Mazzulli
Dr. T. Mazzulli
March 09, 2009
November 18, 2009
Dr. T. Mazzulli
Dr. T. Mazzulli
November 18, 2009
Dr. T. Mazzulli
November 18, 2009
May 17, 2010
May 17, 2010
May 17, 2010
January 10, 2011
January 31, 2011
January 31, 2011
January 31, 2011
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT
NOTE: This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked
against the document (titled as above) on the server prior to use.
D:\533562715.doc
Policy # MI/SER/v48
Page 93 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Page Number / Item
Date of Revision
Updated VZV procedure
Updated Appendix II
Updated Architect procedure
Removed Appendix III – Send out procedure to St.
Joseph Hospital, Hamilton ON
Replaced Appendix III - Daily work-up for Architect
Bench
Moved PCP DFA from Virology Section
Annual Review
Architect system – added HTLV
Removed HTLV for TGLN
Added to Table of Contents
Donor Serology and Molecular Testing at Mount Sinai
Hospital for TGLN
Architect system – added CMV IgM and CMV avidity
Annual Review
Edited CMV Avidity testing procedure
Added Appendix XI and XII – CMV Avidity workflow
Edited Architect system
Edited EBV serology
Edited Autoverification procedure
Removed AxSYM HHsAg confirmation
Edited Immucor CMV procedure
Updated Cadaver serology procedure
Edited Syphilis Screen RPR Serology procedure
Updated Architect daily workflow
Added George Washington CMV avidity confirmation
algorithm
Updated Appendix IV – Entering and Verifying Refeerout Serology Results
Updated EBV Serology, reference added
Annual Review
Edited George Washington CMV avidity confirmation
algorithm
Added George Washington Anti-HCV algorithm
Updated TGLN Call Back procedure
Updated Architect section
Updated Appendix IV – refer-out tests reporting
Update Architecht, Axsym, DONOR, Immucor, appdx3,
appdx 5
Signature of
Approval
January 31, 2011
January 31, 2011
May 31, 2011
May 31, 2011
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
May 31, 2011
Dr. T. Mazzulli
May 31, 2011
May 31, 2011
June 20, 2011
June 20, 2011
July 15, 2011
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
March 20, 2012
March 20, 2012
September 12, 2012
September 12, 2012
September 30, 2012
September 30, 2012
September 30, 2012
September 30, 2012
September 30, 2012
September 30, 2012
September 30, 2012
September 30, 2012
January 28, 2013
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
February 12, 2013
Dr. T. Mazzulli
February 28, 2013
April 18, 2013
April 18, 2013
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
April 18, 2013
May 21, 2013
May 31, 2013
May 31, 2013
September 17, 2013
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT
NOTE: This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked
against the document (titled as above) on the server prior to use.
D:\533562715.doc
Policy # MI/SER/v48
Page 94 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Page Number / Item
Date of Revision
Addition Appendix XII, modify appendix I and III, delete
appendix VII
Edit Appendix XII, include chemical waste transport.
Moved GW in its own section. Add reporting/ receiving
section. Update Appendix XII include easy mag transport
EBV VCA IgG/EBV EBNA-1 IgG addition to architect
manual.
GW HC flowchart update, GW confirm algorithm update
GW HCV flowchart update, Appendix update, Axsym
manual update – remove CMV
Appendix III update
Removal of Axsym manual. Addition of Donor section to
Architect Manual. Note addition to STAT needlestick
incident reporting
Annual review
Remove Evolis donor manual, replace with Gw hcae
evolis manual
Update Architect manual.
Removal of Evolis donor testing
Fix headers/footers
Indeterminate CMV Immucor interpretation added.
TGLN section removed and copied to standalone TGLN
call back procedure. Link to this manual created.
GW procedure: CMV Avidity Troubleshooting added:
diluting sample when CMV IgG is too high to calculate
avidity
Donor testing RPR to 8VD
-Wash buffer filling replaced with ARM procedure.
-Added under Donor/Recipient Serology reporting:
Reporting REACTIVE results for Alberta Donors
only: - If repeat results support the initial Reactive result,
enter repeat results in the result comment and verify
results. - If repeat results DO NOT support the initial
result, type “Note” at result area, enter initial result and
repeat results in the comment and verify results.
-Donor/Recipient resulting divided into Ontario living
donor and non-ontario &cadaveric donor sections
Hep C Ab, HIV , HTLV and VD for living donor:
Repeatedly positive report as ‘reactive’ with comment
“Repeatedly reactive, sent to PHL for further testing”
Annual Review
Signature of
Approval
October 30, 2013
Dr. T. Mazzulli
January 15, 2014
January 27, 2014
Dr. T. Mazzulli
Dr. T. Mazzulli
March 11,2014
Dr. T. Mazzulli
March 14, 2014
March 27, 2014
Dr. T. Mazzulli
Dr. T. Mazzulli
April 4, 2014
May 28, 2014
Dr. T. Mazzulli
Dr. T. Mazzulli
October 24, 2014
Dr. T. Mazzulli
May 1, 2015
Dr. T. Mazzulli
May 1, 2015
Dr. T. Mazzulli
June 17, 2015
Dr. T. Mazzulli
August 7, 2015
Dr. T. Mazzulli
October 15, 2015
Dr. T. Mazzulli
UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT
NOTE: This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked
against the document (titled as above) on the server prior to use.
D:\533562715.doc
Policy # MI/SER/v48
Page 95 of 116
Microbiology Department
Policy & Procedure Manual
Section: Serology Manual
Page Number / Item
Date of Revision
Remove 8HAG (replace with 8HAGX)
Remove 8HBEB, 8HBEG tests
Update 8HAGX positive reflex procedure/resulting table
Removed flowcharts for 8HAGX algorithm
Update 8HAGX confirmation interpretation table
Added description of reagents used in Working Wash
solution for CMV Immucor.
Remove Alberta Only reporting for Donors
Add donor storage instructions
Updated Donor reporting table
p.3 Immucor CMV for wash solution added phrase:
‘Mark ‘ Date Made’ on Working Wash Solution bottle.’
p.4 Immucor CMV: step 8: changed from wash gently 5
times to gently 6 times.
p.4 Immucor CMV: Interpretation of results for Donors
removed: ‘Donor samples received from the architect
bench (8HAGX) for Capture-CMV testing must be
resulted and verified under both 8CMSE and 8CMS’
p.4 Step 11 inserted RCF specific to ImmuSpin
centrifuge programming.
p.5 Immucor CMV: QC changed external controls from
Run Virotrol I /ViroTorch to ViroTorch/ ViroTorch-M.
p.5 Immucor CMV: Reference updated with version:
9/10
October 29, 2015
Signature of
Approval
Dr. T. Mazzulli
UNIVERSITY HEALTH NETWORK / MOUNT SINAI HOSPITAL MICROBIOLOGY DEPARTMENT
NOTE: This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked
against the document (titled as above) on the server prior to use.
D:\533562715.doc