Guide and Requirements to Set-up a Medical or Clinical Laboratory in the Philippines: Free Standing or Hospital Based

A medical laboratory or clinical laboratory is a laboratory where tests are usually done on clinical specimens in order to obtain information about the health of a patient as pertaining to the diagnosis, treatment, and prevention of disease. Clinical laboratories are thus focused on applied science mainly on a production-like basis, as opposed to research laboratories that focus on basic science on an academic basis.

If you're planning to set-up a clinical laboratory in the Philippines, either a Free Standing or Hospital Based, below is a step by step guide and requirements including equipment, personnel and floor plan needed for acquiring a license.

Form to be used:

Application for Permit to Construct a Clinical Laboratory

Licensing Fees:

Licensing fees to acquire a license

Where to File:

BUREAU OF HEALTH FACILITIES AND SERVICES (BHFS)
Address: Bldg. 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila

How to File:

Submit the application form to the Bureau of Health Facilities and Services. A copy of Permit to construct and Approved Floor Layouts shall be issued within 15 working days upon receipt of application provided that all documents are complete and compliant.

Note: Refer below for the services or tests to be offered per category

A. LICENSING REQUIREMENTS OF A CLINICAL LABORATORY SERVICE CAPABILITY

PRIMARY CATEGORY
  - Routine Fecalysis

  - Routine Urinalysis

  - Routine Hematology

      (Complete Blood Count or CBC) includes Hemoglobin Mass Concentration, Erythrocyte Volume       Fraction (Hematocrit), Leucocytes Number Concentration (White Blood Cell or WBC Count),             Leucocytes Type Number Fraction (Differential Count) and Qualitative Platelet Determination

  - Blood Typing (Hospital-Based)
  - Quantitative platelet determination (Hospital-Based)

SECONDARY CATEGORY
  - ALL those in Primary Category PLUS the following:
  - Routine Clinical Chemistry includes Blood Glucose Substance Concentration, Blood Urea                   Nitrogen Concentration, Blood Uric Acid Substance Concentration, Blood Creatinine                           Concentration and Blood Total Cholesterol Concentration
  - Cross matching (Hospital-Based)

TERTIARY CATEGORY
  - ALL those in Secondary Category PLUS the following:
  - Immunology/Serology
  - Microbiology
  - Special Chemistry
  - Special Hematology

B. PERSONNEL

1. The Clinical Laboratory shall be managed by a licensed physician certified by the Philippine Board of Pathology.

1.1. In areas where pathologists are not available, a physician with a three (3) months training on clinical laboratory medicine, quality control and laboratory management, may manage a primary/secondary category clinical laboratories. The BHFS shall certify such training.

2. The clinical laboratory shall employ qualified and adequately trained personnel. Work assignment shall be consistent with the qualification of the concerned personnel.

2.1. A clinical laboratory shall have sufficient number of registered medical technologists proportional to the workload and shall available at all times during hours of laboratory operation. For hospital-based clinical laboratory, there shall be at least one registered medical technologist per shift to cover the laboratory operation.

3. There shall be staff development and appropriate continuing education program available at all levels of organization to upgrade the knowledge, attitudes and skills of staff.

C. EQUIPMENT/INSTRUMENTS

1. There shall be sufficient number and types of appropriate equipment/instrument in order to undertake all the laboratory examinations and procedures. The equipment/instrument shall comply with safety requirements.

PRIMARY CATEGORY
  - Clinical centrifuge
  - Differential blood cell counter or its equivalent
  - Hemacytometer

  - Hemoglobinometer or its equivalent
  - Microhematocrit centrifuge

  - Microscope w/ oil immersion objective

SECONDARY CATEGORY
  - ALL those in Primary Category PLUS the following:
  - Photometer or its equivalent
  - Refrigerator
  - Timer or its equivalent
  - Water bath or its equivalent

TERTIARY CATEGORY
  - ALL those in Secondary Category PLUS the following:
  - Autoclave
  - Balance, trip/analytical
  - Biological Safety cabinet or its equivalent
  - Drying oven
  - Incubator
  - Rotator
  - Clinical Centrifuge or its equivalent

2. For other laboratory examinations being performed, the appropriate equipment for performing such procedures shall be made available.

D. FLOOR PLAN REQUIREMENT
1. Adequate area shall be provided for the people, activity, furniture, equipment and utility.

PRIMARY CATEGORY
  - Minimum of 10 square meters in floor area
  -  Access to Toilet
  - Clinical Work Area with Sink
  - Pathologist Area

SECONDARY CATEGORY
  - Minimum of 20 square meters in floor area
  - Toilet
  - Clinical Work Area with Sink
  - Pathologist Area

TERTIARY CATEGORY
  - Minimum of 60 square meters in floor area
  - Toilet
  - Clinical Work Area with Sink
  - Pathologist Area
  - Microbiology Room

2. A clinical laboratory shall be of such construction so that no hazards to the life and safety of patients, personnel and public exist. It shall be capable of withstanding weight and elements to which they may be subjected.

3. It shall be provided with sufficient illumination and adequate ventilation to enable personnel in the performance of work and to ensure comfort of patients, personnel and public.

4. Floors, walls, ceilings, fixtures and furniture shall be of sturdy materials that shall allow durability, ease of cleaning, fire and acid resistance.

5. There shall be measures for detecting fire such as fire alarms in walls, peepholes in doors or smoke detectors in ceilings. There shall be devices for quenching fire such as fire extinguishers or fire hoses that are easily visible and accessible in strategic areas.

6. Proper maintenance shall be provided to prevent untimely breakdown of building and equipment.

7. Liquid waste shall be discharged into an approved public sewerage system, and solid waste shall be collected, treated and disposed of in accordance with applicable codes, laws or ordinances.

8. References shall be made to the following:

• P. D. 1096 National Building Code of the Philippines and Its Implementing Rules and Regulations
• P. D. 1185 Fire Code of the Philippines and Its Implementing Rules and Regulations
• P. D. 856 Code on Sanitation of the Philippines and Its Implementing Rules and Regulations
• R. A. 1378 National Plumbing Code of the Philippines and Its Implementing Rules and Regulations
• R. A. 184 Philippine Electrical Code Manual on Technical Guidelines for Hospitals and Health Facilities Planning and Design. Department of Health, Manila. 1994
• Health Facilities Maintenance Manual. Department of Health, Manila. 1995
• Manual on Hospital Waste Management. Department of Health, Manila. 1997

Other Documentary Requirements:

• Form No. 4-01: Application for Permit to Construct notarized
• Letter of Application to the Director of the Bureau of Health Facilities and Services
• Letter of Endorsement from the Director of the Center for Health Development
• Four (4) Sets of Floor Layout, showing location of equipment and areas required, appropriately dimension, properly identified and completely labeled
• DTI/SEC Registration (for private clinical laboratory)

What we can offer:

• IF YOU'RE LOOKING FOR A SUPPLIER FOR AFFORDABLE EQUIPMENT AND INSTRUMENTS FOR YOUR LABORATORY SET-UP, PLEASE DON'T HESITATE TO CONTACT US. WE'LL BE HAPPY TO ASSIST YOU AND SEND YOU A QUOTATION/PROPOSAL. WE WILL ALSO ASSIST FOR THE DOCUMENTATIONS NEEDED TO ACQUIRE A LICENSE (e.g. S.O.P.)

Prothrombin Time Test- Principle and Interpretation

Prothrombin Time tests the extrinsic coagulation pathway and is useful for detecting coagulation deficiencies, liver disease and disseminated intravascular coagulation (DIC). The prothrombin time (PT) is also the main monitor for coumarin therapy (e.g. warfarin), expressed as a ratio—the international normalized ratio (INR). The test measures the clotting time of plasma in the presence of a tissue extract, e.g. brain (thromboplastin). The test measures prothrombin but also factors V, VII, and X. 

Sample: Citrate

Increase Prothrombin time

• Oral anticoagulation therapy (vitamin K antagonists)
• Fibrinogen deficiency (factor I)
• Prothrombin deficiency (factor II)
• Deficiency of factors V, VII or X (in V or X deficiency the activated partial thromboplastin time APTT will be increase)
• Liver disease especially obstructive
• Vitamin K deficiency
• DIC

Ham’s Acid Lysis Test: Principle and Interpretation

Ham’s Acid Lysis Test is a test for the rare acquired red cell membrane disorder called paroxysmal nocturnal haemoglobinuria (PNH). Its pathophysiology is complex and involves an abnormality of the red cell membrane in PNH making it prone to complement-mediated lysis and episodes of marked intravascular haemolysis leading to free Hb in the urine (haemoglobinuria).

Principle

• Abnormal sensitivity of RBCs from patients with PNH to the haemolytic action of complement.
• Complement is activated by acidification of the patient’s serum to pH of 6.2, which induces lysis of PNH red cells, but not normal controls.

Sample: EDTA, heparin, citrate, oxalate.

Result: Positive result indicates PNH.

Specificity: High—similar reaction is produced only in the rare syndrome HEMPAS (a form of congenital dyserythropoietic anaemia type II), which should be easily distinguished morphologically. 

Sensitivity: Low—as the reaction is crucially dependent on the concentration of magnesium in the serum.

Bleeding Time- Ivy Method (Template Bleeding Time): Principle, Procedure and Reference Value

Bleeding Time- Ivy Method (Template Bleeding Time)

Principle

Bleeding time measures the primary phase of hemostasis: the interaction of the platelet with the blood vessel wall and the formation of a hemostatic plug. Bleeding time is the best single screening test for platelet function disorders and is one of the primary screening tests for coagulation disorders.

This test is of value in detecting vascular abnormalities and platelet abnormalities or deficiencies. It is not recommended for routine presurgical workup.

A small stab wound is made in either the earlobe or the forearm; the bleeding time (the amount of time it takes to form a clot) is recorded. The duration of bleeding from a punctured capillary depends on the quantity and quality of platelets and the ability of the blood vessel wall to constrict.

The principal use of this test today is in the diagnosis of von Willebrand's disease, an inherited defective molecule of factor VIII and a type of pseudohemophilia. It has been established that aspirin may cause abnormal bleeding in some normal persons, but the bleeding time test has not proved consistently valuable in identifying such persons.

Procedure

1. Cleanse the area three fingerwidths below the antecubital space with alcohol and allow to dry.
2. Place a blood pressure cuff on the arm above the elbow and inflate to 40 mm Hg.
3. Select a cleansed area of the forearm without superficial veins. Stretch the skin laterally and tautly between the thumb and forefinger.
4. Start a stopwatch. Use the edge of a 4? × 4? filter paper to blot the blood through capillary action by gently touching the drop every 30 seconds. Do not disturb the wound itself. Remove the blood pressure gauge when bleeding stops and a clot has formed. Apply a sterile dressing when the test is completed.
5. Remember that the end point (by the Ivy or the earlobe method) is reached when blood is no longer blotted from the forearm puncture. Report in minutes and half minutes (eg, 5 minutes, 30 seconds).

Reference Values

Normal 3–10 minutes in most laboratories Duke method (earlobe): 5 minutes (not recommended—not very reproducible with a wide range of normal values) Ivy method (forearm with template): 25–90 minutes Mielke's method (Surgicut): Adults: 1–7 minutes Teens: 3.0–8 minutes Children: 2.5–13 minutes

Clinical Implications

1. Bleeding time is prolonged when the level of platelets is decreased or when platelets qualitatively abnormal:

• Thrombocytopenia (platelet count <80 × 10 3/mm 3)
• Platelet dysfunction syndromes
• Decrease or abnormality in plasma factors (eg, von Willebrand's factor, fibrinogen)
• Abnormalities in the walls of the small blood vessels, vascular disease
• Advanced renal failure
• Severe liver disease
• Leukemia, other myeloproliferative diseases
• Scurvy
• DIC disease (owing to the presence of FDPs)

2. In von Willebrand's disease, bleeding time can be variable; it will definitely be prolonged if aspirin is taken before testing (aspirin tolerance test).

3. A single prolonged bleeding time does not prove the existence of hemorrhagic disease. Because a larger vessel can be punctured, the puncture should be repeated on an alternate body site, and the two values obtained should be averaged.

4. Bleeding time is normal in the presence of coagulation disorders other than platelet dysfunction, vascular disease, or von Willebrand's disease.

5. Aspirin therapy (antiplatelet function therapy): when thrombus formation is thought to be mediated by platelet activation, the patient frequently is given agents to interrupt normal platelet function, which may be monitored by bleeding times or platelet aggregation studies. Aspirin is the most commonly used inhibitor; it inhibits platelet

Interfering Factors

• Normal values for bleeding time vary when the puncture site is not of uniform depth and width.
• Touching the puncture site during this test will break off fibrin particles and prolong the bleeding time.
• Excessive alcohol consumption (as in alcoholic patients) may cause increased bleeding time.
• Prolonged bleeding time can reflect ingestion of 10 g of aspirin as long as 5 days before the test.
• Other drugs that may cause increased bleeding times include dextran, streptokinase-streptodornase (fibrinolytic agents), mithramycin, pantothenyl alcohol.
• Extreme hot or cold conditions can alter the results.
• Edema of patient's hands or cyanotic hands will invalidate the test.

AnaPrep Automated DNA and RNA Purification System

AnaPrep
image source: www.biochain.com

Overview

BioChain’s AnaPrep system is a fully automated nucleic acid extraction platform that is efficient, effective and economical. Based on the latest magnetic bead technology, AnaPrep is easy to use with three simple steps: load samples, run pre-programmed protocols, and collect purified samples. The end result is reproducible high quality nucleic acids from a wide range of starting materials that are ready for a variety of downstream applications.

Features/ Benefits:

• Automated processing of 1 to up to 24 samples with pre-programmed protocols
• Consistent high purity nucleic acid using reliable reagents and methods
• Saves time and labor with pre-filled reagent cartridges and disposables
• Flexible design for processing customized sample numbers and elution volume (50-300ul).
• For research use only in the US, manufactured under GMP, ISO13485, and CE marking
• Minimizes contamination risks with unidirectional sample head and built-in UV lamp
• Versatile system enables purification from various sample sources and the products are suitable for many downstream applications
• Easy to Use and Error-free with simple steps, fool-proof design, and barcode reader
• Conserves space with an all-in-one, compact instrument 

Principle

The efficiency of AnaPrep stems from making the extraction process easy. 

AnaPrep combines the latest magnetic bead separation technique with strict quality control systems for reagents and liquid handling to obtain pure extraction. Researchers save time, labor, and avoid mistakes by using pre-filled reagent cartridges and disposable plastics. The purification process is as fast as 40 minutes for 1-12 or 24 samples. 

With an integrated processing unit that carries out the preloaded protocols, AnaPrep eliminates the requirement for an external computer. AnaPrep comes with a barcode reader enabling quick selection of protocols. The seamless automation provides the user the ability to simply place the samples in the machine, select a pre-programmed protocol, walk away, and let the machine carry out the tedious steps required for extraction. All processing procedures are done by the instrument, from piercing the reagent cartridge to eluting the pure nucleic acid. Using the machine is easy and does not require training in automation. 

Specimen Application 

Versatility in any system affords users the resources to expand their work and AnaPrep is such a system. DNA from broad sample sources, such as blood, tissue, and FFPE have been successfully purified with AnaPrep extraction kits. The purified nucleic acids are immediately suitable for a broad range of downstream applications.

AnaPrep System is able to purify nucleic acid from the following biospecimen:

• Whole blood 
• FFPE
• Saliva
• Stool
• Serum 
• Tissue
• CSF
• Plasma
• Cell
• Urine
• Buffy Coat
• Swab
• Sputum 

Downstream Applications

• PCR
• qPCR
• Next generation sequencing
• Restriction enzyme digestion
• Hybridization
• SNP analysis
• Genotyping
• NAT, oncology, forensics, food inspection, GMO
• Molecular diagnosis (for applications sufficient with CE marking, or in LDT). For research use only in the US.

For detailed info, visit: biochain.com

In Vitro Phagocytosis: Principle, Materials and Procedure

Principle

A drop of whole blood is mixed with a drop of a bacterial culture and incubated at room temperature to demonstrate engulfment of bacteria by leukocytes.

Materials

• Test tubes, 12 75 mm 
• Broth culture of Staphylococcus epidermidis 
• Lancets for finger puncture 
• Heparinized microhematocrit tubes 
• Microscope slides 
• Wright stain

Procedure

1. Take two 12 75 mm test tubes and label one 0 minutes and the other 5 minutes. If there is enough blood available, a 10-minute tube can also be set up.
2. Do a finger puncture and fill a heparinized microhematocrit tube about three-quarters full of blood. Note that blood drawn in an EDTA tube within the last 10 minutes can also be used.
3. Using a black rubber bulb, expel one drop of blood into each labeled test tube.
4. Add one drop of Staphylococcus epidermidis culture to each tube, using a disposable Pasteur pipette. The culture should be no more than a 0.5 McFarland standard in concentration. Dilute in an additional broth tube or in sterile saline if necessary.
5. Shake the tubes to mix, and make a blood film of the 0 tube immediately. Let the other tubes incubate for 5 minutes and 10 minutes, respectively, at room temperature before making blood films of them. 

Method for Making Blood Smears

1. Obtain two clean glass slides, one of which will be used as a spreader slide.
2. With a Pasteur pipette, carefully place a small drop of blood at one end of a microscope slide.
3. Holding the spreader slide with the thumb and forefinger, place the spreader slide slightly in front of the drop of blood on the other slide, maintaining a 25-degree angle between the slides.
4. Move the spreader slide back toward the drop of blood. As soon as the slide comes in contact with the drop of blood, the blood will start to spread along the edge.
5. Keeping the spreader slide at a 25-degree angle, push it rapidly over the length of the slide. There should be a feathered edge on the end of the smear. 

Wright Stain

1. Allow the blood smear to air dry.
2. Stain according to typical laboratory protocol for staining blood smears.
3. Blot the back of the slides to remove excess stain and let them air dry.
4. Use immersion oil and look for engulfment.

Interpretation/Analysis

These blood smears will be more watery than usual due to the addition of the broth culture with bacteria; therefore, it may be difficult to get a blood smear with a feathered edge. The feathered edge is not essential, as long as the blood cells are spread out on the slide. There should be a noticeable difference between the 0- and the 5-minute slide. The 0-minute slide will probably not show much engulfment, but bacteria may be seen in contact with leukocytes. The 5-minute slide should show bacteria within the cell as small purple dots. Neutrophils will be the predominant phagocytic cells, but an occasional monocyte may be seen. If lymphocytes are the only white blood cell seen, the bacterial suspension was too heavy, and the phagocytic cells destroyed themselves in attempting to engulf the bacteria present.

Centrifuges: Functions and Laboratory Applications

Sorvall Legend Micro 17 and 21 Microcentrifuge Series

Image Courtesy of Thermo Scientific

A number of types of centrifuges are specialized in their uses. They are all used to spin biological samples to separate components within the specimen. Centrifugal forces cause the heavier materials to go to the bottom of the tubes. Samples are centrifuged at speeds that vary by procedure and type of sample. Most commonly, blood is separated for tests where the liquid portion (serum or plasma) is to be used in the procedure.

Specimens that require blood cells would not normally require centrifugation. The basic parts of the centrifuge, regardless of type, are similar. The rotor is the part that is spun by the motor of the centrifuge, and is controlled by a timer and a speed control. Centrifuges are differentiated by the jobs for which they were developed.

Common centrifuges used for separating blood into solid and liquid components whether as plasma (derived from anticoagulated specimens) or serum (obtained from clotted samples) are the most numerous types found in the laboratory, and most laboratories have at least several of each for basic types.. A microcentrifuge, or microfuge, is one that is used to spin small tubes at high speeds that may be as great as 14,000 rpm (revolutions per minute). Other models, called clinical centrifuges, operate in the range of up to roughly 3,000 rpm, and are used to concentrate sediment from urine samples and to separate serum or plasma from whole blood samples. One common specialized centrifuge used in blood banking, or immunohematology is the serofuge, for use in washing of red blood cells in small tubes of 2 to 3 mL. Other centrifuges may be required depending on types of specimens and procedures. Some require high-speed refrigerated centrifuges; some require various types of specimens and differing sizes of collection tubes and containers.

Job Opportunities for Medical Laboratory Professionals

Are you planning to pursue a career in medical laboratory profession and worried about your employment after graduation? Or just passed the licensure examination and you have no idea where to start your job search? 

There are a vast number of areas in which one may find employment in a medical laboratory. There are also a considerable number of names or occupational specialties by which the laboratory professional may be classified, depending on where one works and the job position occupied. In addition, the various agencies and state licensing bodies will confer varying titles on the medical laboratory worker. While the majority of clinical laboratory workers are employed by hospital laboratories, there are numerous other opportunities for interesting and rewarding employment, ranging from the most common employment as a professional in the hospital setting to positions in the business sector as well as in educational institutions, and even in research or in legal categories of work such as in a state crime laboratory. Among these general categories of employment, there are numerous specialties within these overall areas.

Specific examples of some of these job opportunities are in government research laboratories or pharmaceutical companies that use medical laboratorians to produce data and compile research information for new medications and their effects on patients. Commercial reference laboratories are commonly used by hospital laboratories for seldom-requested tests and for special procedures that are not economically feasible due to the time, equipment, or supplies needed for the testing or that are beyond the abilities of the routine laboratories. To a lesser extent, POLs (which often provide for more flexible scheduling than hospital laboratories), state or federal crime laboratories, and the education setting are other avenues to pursue for meaningful employment. Laboratory professionals on all levels are gaining lucrative employment in sales for equipment and expendable supplies, product development, training of workers to use new equipment, and technical service departments of major manufacturers. An increasing need for medical laboratory workers of all specialties and designations has spurred the enrollment of greater numbers of students pursuing a laboratory vocation in the past few years and is continuing.