At our health system facilities, we use a Kova system in the outreach
laboratories and an automated analyzer in the main lab.  For both of these
methods, as soon as >100 RBCs/hpf is reached, the results are reported as
TNTC (too numerous to count).  All other elements are counted/graded and
reported as usual.  For our outreach sites, they use a phase 'scope and have
a further distinction as well:  If the field is so packed with RBCs that you
cannot distinguish any other elements, then the only result reported is TNTC
RBCs with the comment "Field Obscured by RBCs.  Unable to determine presence
or absence of other elements."  This allows the physician to make the
determination of what to do next.  Usually, we get a request to add a
culture to these unless they are known kidney stones, trauma, etc.

I have heard of other facilities doing dilutions on these types of
specimens, but I haven't done this myself.  I do not know of any NAACLS
guidelines, and would normally be happy to look these up for you, but I've
got a CLIA inspection coming up and just jumped on here for a sec to see
what was going on in labworld. :) Judy or Manky may be able to give more
information on this.

Shylirin

Few facilities I know have a written procedure dealing with this situation.

Generally, if the sample is red and cloudy, I perform dipstick testing on
the mixed sample and on the supernatant, and look for significant
differences that can be attributed to red cells on the pads.  Next, I
prepare a microscopic exam with and without acetic acid (lyses red cells)
and again compare the results.  Finally, I decide what to report from the
information I have, giving the physician the most clinically relavent
information I can get from the sample.  I always comment the results, so the
physician understands the limitations of the results.

If there is a bladder bleed from some lesion, the red cells will probably be
the only significant finding.  If after lysing the red cells, I see WBCs and
bacteria, a UTI is the better reason.  Just reporting that the field is
obscured doesn't give the physician any information he didn't know before
the sample was sent to the lab, and an exact quantitation above a certain
point is meaningless.

On really, really bloody urines, I have had an occasional request for a
hematocrit, presumably to see if it approaches the CBC's crit value.

Larry Smrz, MBA, MT(ASCP)SBB, CQA(ASQ)
Indianapolis, IN