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1 ASCLS-NJ 2016
Quality Control of Hematology Critical Values:
What to do and What NOT to do
Joshua Hayden, PhD DABCC FACB Assistant Director, Central Lab
Su-Chieh (Pam) Sun MPA, MT(ASCP) Supervisor, Hematology
2 ASCLS-NJ 2016
Welcome to your new job…
Plt of 5x103/μL?!? I better…
That Plt was wrong!!! I just transfused a
patient for no reason!
My patient needs Plts!Why did it take you so long
to report that value!!!
…report this as fast as possible …make sure this result is correct
3 ASCLS-NJ 2016
• Pre-analytic errors (and how to detect them?)
• When to perform manual intervention
• Whether or not to repeat critical values?
4 ASCLS-NJ 2016
• Pre-analytic errors (and how to detect them?)
• When to perform manual intervention
• Whether or not to repeat critical values?
5 ASCLS-NJ 2016
Do pre-analytical errors ever happen?
Doc didn’t believe the patient was
hyperkalemic so I am double checking
these QC recordsI need new co-workers
6 ASCLS-NJ 2016
Pre-analytic errors
• Account for highest errors in testing process
• Common Errors Misidentification
Clotted / Incorrect volume
Lipemic / Hemolysis / Contamination
7 ASCLS-NJ 2016
Example 1
8 ASCLS-NJ 2016
What to do?
• Instrument flags?
• Spurious results?
• Delta check pass?
• Sample Integrity?
• Specimen ID?
9 ASCLS-NJ 2016
Sample Mixups
Patient AHct 9% CF
Patient BHct 49%
Wrong blood in tube 1/1300 – 1/2700↑ rate with non-phlebotomy/lab collect
Br J Haematol. 2015 Jan;168(1):3-13
EHRPatient APrior Hct 50%
Patient BPrior Hct 11%
Pt
AP
t B
10 ASCLS-NJ 2016
Delta ChecksEHRPatient A
Prior Hct 50%
Patient BPrior Hct 11%
Pt
AP
t B
Delta Check|Prior Hct – Current HCT |
< 9% Report> 9% STOP
11 ASCLS-NJ 2016
Delta Checks (might be) AWESOME!EHRPatient A
Prior Hct 50%
Patient BPrior Hct 11%
Pt
AP
t B
Patient APrior: 50%Current: 9%|50% - 9% | > 9%
Patient BPrior: 11%Current: 50%|11% - 50% | > 9%
Middleware
Hold results, notifytechnologist
12 ASCLS-NJ 2016
Delta Checks (might be) not awesomeEHRPatient A
Prior Hct 50%
Patient BPrior Hct 11%
Patient APrior: 50%Current: 39%|50% - 39% | > 9%
Patient BPrior: 11%Current: 21%|11% - 21% | > 9%
Middleware
Hold results, notifytechnologist
Patient A
Patient B
Pt
AP
t B
X3
13 ASCLS-NJ 2016
Delta Checks (might be) not awesome
No More Delta Checks!!!!!!
Hold results, notifytechnologist
Hold results, notifytechnologist
Hold results, notifytechnologist
Hold results, notifytechnologist
Hold results, notifytechnologist
Hold results, notifytechnologist
Hold results, notifytechnologist
Hold results, notifytechnologist
14 ASCLS-NJ 2016
Utility of Delta Checks varies by analyte
and Medical Center (M.C.)
Del
ta C
hec
k C
alcu
lati
on
Clinica Chimica Acta. 2011;21:1973–1977
MC #1 (AUC)
MC #2(AUC)
MCV 0.93 0.93
HCT 0.85 0.79
GLU 0.66 0.65
K 0.66 0.67
AUC = 0.5
MC#1: trauma and critical careMC#2: cancer and transplant hospital
(frequent transfusions)
15 ASCLS-NJ 2016
How to make Delta Checks useless
Hold results, notify
technologist
Verify inEHR
Act
ion
fo
llow
ing
Del
ta C
he
cks
Rate of False Positive Delta Check0%
100%
Hayden et al, unpublished
16 ASCLS-NJ 2016
Example 2
17 ASCLS-NJ 2016
What to do?
18 ASCLS-NJ 2016
What is the most common reason for
specimen rejection in the clinical laboratory?
Mislabel?
Wrong tube?
Inadequate volume?
Hemolysis?
Icterus?
Lipemia?
Clotted sample?
Specimen stability?
19 ASCLS-NJ 2016
And the winner is…..
Clinical Chemistry and Laboratory
Medicine. Volume 46, Issue 6, Pages
764–772
Hemolysis
Clin Biochem. 2014 Aug;47(12):1002-5.
Clotted sample
Biochem Med (Zagreb). 2015 Oct 15; 25(3): 377–
385.
Clotted sample
Clin Chem Lab Med. 2011 Oct 14;49(12):2047-
50
Clotted sample
20 ASCLS-NJ 2016
How can you check for clotted samples?
CAP Standard HEM. 22150CBC specimens are checked for clots (visual, applicator, or automated analyzer histogram inspection/flags) before reporting results.
21 ASCLS-NJ 2016
Clotted Specimen Example 1
22 ASCLS-NJ 2016
Clotted Specimen Example 2
23 ASCLS-NJ 2016
Clotted Specimen Example 3
?
?
24 ASCLS-NJ 2016
Delta Check fails indicates further investigation
• Sample mix up? (MCV, HGB, PLT)• Clotted specimen?• Contaminated specimen?• Check for spurious results?• True change in patient status?
25 ASCLS-NJ 2016
Recognize instrument flag and histogram • Check for sample integrity• Check for spurious results
Specimen Integrity should be confirmed prior to reporting any critical values
• false negative instrument flags• Insensitive delta check rule
26 ASCLS-NJ 2016
• Pre-analytic errors (and how to detect them?)
• When to perform manual intervention
• Whether or not to repeat critical values?
27 ASCLS-NJ 2016
Example 2
28 ASCLS-NJ 2016
Example 2Post-warm
29 ASCLS-NJ 2016
Example 2Before and After
30 ASCLS-NJ 2016
Example 3
31 ASCLS-NJ 2016
When to perform manual microscopy
I don’t trust you
32 ASCLS-NJ 2016
Would you report a critically low PLT on
this patient?
http://www.sun.ac.za/english/faculty/healthsciences/haematological_pathology/Pages/Platelet-morphology.aspx
33 ASCLS-NJ 2016
Would you report a critically low PLT on
this patient?
Leukemia Practical Clinical Hematology. Cytochemical Reactions in Acute Leukemia Blasts Identified Cellular Element Stained Cytochemical Reaction Myeloblasts.
34 ASCLS-NJ 2016
Know the analyzer!Sysmex Coulter Advia
35 ASCLS-NJ 2016
When to perform manual microscopy
• New patient
• Flagged result
• Failed delta
36 ASCLS-NJ 2016
• Pre-analytic errors (and how to detect them?)
• When to perform manual intervention
• Whether or not to repeat critical values?
37 ASCLS-NJ 2016
To repeat or not to repeat…that is the
question?
IncreasedAccuracy (?)
38 ASCLS-NJ 2016
How to investigate the utility of repeating
critical values
39 ASCLS-NJ 2016
Analytical repeats are not necessary on
the Beckman DxH
40 ASCLS-NJ 2016
Repeating critical values wastes
resources
Workflow analysis by Juan David Garcia, MBA
41 ASCLS-NJ 2016
Repeating Critical values delays TAT
42 ASCLS-NJ 2016
Repeating critical values delays
necessary clinical action
43 ASCLS-NJ 2016
Hematology Critical Value Workflow at
NYPH - WC
Hgb, Hct, WBC Plt
44 ASCLS-NJ 2016
Juan David Garcia, MBA (Manager, Clinical Laboratory Services)
Hematology Technologists, NYPH-WC
Stephen Master, MD PhD (Medical Director, Central Laboratory)
Acknowledgements
45 ASCLS-NJ 2016
Questions?
Hgb, Hct, WBC Plt