SEED Haematology

Sysmex Educational Enhancement and Development

July 2013

Internal quality control in haematology

– for the sake of the patient.

What is quality assurance? of specially prepared control blood materials on the same
The laboratory plays a pivotal role in medical practice as test haematology analysers that are used to test patient samples.
results have major influence on clinical diagnosis and patient It also includes day by day monitoring of these measure-
management. The laboratory therefore has an ethical obliga- ments to ensure that the values obtained are within prede-
tion to produce reliable and reproducible test results and termined limits. This process is referred to as ‘internal qual-
to provide clinicians with unambiguous meaningful reports ity control’ as it constitutes a continuous self-evaluation of
that are relevant for the clinical problem being investigated. the reliability of the results generated by the laboratory
Quality assurance is the sum of all activities that a laboratory before reports are issued.
must undertake to ensure that results generated are reliable
and correct. By strict adherence to quality assurance pro- An additional quality control activity is the participation in
cesses any mistakes should be found and corrected before external quality assessment schemes (EQAS). This process
patient results are released thereby avoiding any adverse is referred to as ‘external quality control’. The details of this
outcomes. A key element of any quality assurance pro- are beyond the scope of this edition.
gramme is the fact that the laboratory must aim to strive
for continuing improvement through constant feedback Why is quality control important?
and corrective action. It is of critical importance that doctors and other healthcare
workers are able to confidently rely on laboratory test results
The major activities of a typical quality assurance process in order to make meaningful and safe decisions about the
can be divided into three main phases, namely preventative, diagnosis and treatment of patients entrusted into their care.
assessment and corrective action as shown in Tab. 1. If results are produced in a quality controlled manner then a
doctor can safely assume that any deviation from normal or
What is internal quality control? any change from a previous result is solely due to the patient’s
The phrase ‘quality control’ is used to refer to the component clinical condition and not due to any technical issue within
of quality assurance that constitutes the assessment or ana- the laboratory.
lytical phase of testing. It includes the repeated measurement

1) P
 reventative (activities performed 2) Assessment (specimen analysis) 3) Corrective action
prior to specimen testing)
■■ Verificationof sample quality ■■ Run internal quality control material ■■ Troubleshooting

■■ Establish
readiness of analytical system ■■ Monitor performance
a) Calibration ■■ Run external quality control material
b) Staff training
c) Instrument maintenance

Tab. 1 The phases and major activities of a typical laboratory quality assurance process
SEED Haematology – Internal quality control in haematology– for the sake of the patient 2
Sysmex Educational Enhancement and Development | July 2013

The role of the Complete Blood Count in clinical and actual analysis. Blood for haematological tests is col-
decision-making lected into tubes that are prefilled with the anticoagulant
In order for doctors to ascertain what is wrong with a patient EDTA. Under-filling of tubes and old samples both tend to
and decide on what treatment to initiate, they go through a give erroneous results that follow a similar pattern. As the
process of asking a series of questions (taking a history) and quality control material that is designed for use on specific
then performing a clinical examination. Invariably however, automated haematology analysers is supplied ready to use
further investigations are usually required before a diagno- any such pre-analytical variables cannot be detected through
sis can be made with certainty. As science and technology routine quality control measures. The laboratory must insti-
progresses, the list of possible investigations gets longer tute a standard operating procedure which requires the fill
and longer, however, laboratory tests continue to make up volume and time of collection to be assessed prior to analy-
70% of investigations that doctors rely on to make diagno- sis, and where necessary, patient samples may need to be
ses. Of all laboratory investigations the complete blood rejected. The temptation to process such specimens in the
count (CBC) is still one of the most commonly requested belief that the laboratory staff are being kind by sparing
laboratory tests. The CBC is thus at the core of almost all doctors the additional work and patients the discomfort of
clinical management decisions. In this context, it is of para- repeating blood sampling must be avoided at all costs as
mount importance that stringent CBC quality control proce- the processing of inadequate specimens may in actual fact
dures are consistently adhered to and that any deviations be harmful as test results are no longer reliable.
are investigated and rectified immediately. The value of a
CBC is only as good as its quality control. Establishing the readiness of the haematology analyser
In order to ensure that the haematology analyser is always
in a state of readiness to perform patient sample analysis,
Patient History
certain core activities need to be adhered to:
Examination
Laboratory
CBC Tests – 70%
Investigations a. Calibration: The great advantage of Sysmex haematology
analysers is that no end-user calibration is required. It is
Clinical the duty of the Sysmex technical representative to ensure
Decision
CBC – most frequently requested laboratory test that the analyser is correctly calibrated at installation and
that this is checked after every breakdown service inter-
Fig. 1 CBC – one of the most frequently requested laboratory tests vention.

What factors can influence the results? b. Staff training: Staff must be properly trained on the
It is important to be aware of the fact that there are several basic operations of the haematology analyser.
pre-analytical factors that can give rise to erroneous test
results as these factors are sample specific and will not be c. Maintenance: All maintenance must be conducted
detected by the standard internal quality control procedures at regular times as prescribed in the official instrument
that will be described later in this text. The main points to operator manual or as advised by an official Sysmex
consider here are the fill volume of the collection tube and representative.
the time delay that has taken place between phlebotomy
SEED Haematology – Internal quality control in haematology– for the sake of the patient 3
Sysmex Educational Enhancement and Development | July 2013

What is meant by an ‘analytical system’? for this detection principle. Furthermore, haematology anal­
The analytical system is defined as the Sysmex haematology ysis involves the measurement of live blood cells (in contrast
analyser plus Sysmex reagents. Quality control samples with to chemistry which primarily involves the measurement of
known values are used to test the analytical system. The inert chemicals). Normal blood cells have a limited lifespan
purpose of running quality control samples is to check the in vivo; red blood cells ~ 120 days, platelets ~ 7–10 days and
reliability of performance of the haematology analytical white blood cells ~ 36 hours although memory lymphocytes
­system. It therefore follows that only Sysmex quality con- may last for several years. However once removed from the
trol blood designed for this purpose should be used. The body, blood cells will disintegrate very rapidly hence the
complete Sysmex analytical package is thus comprised of need to test patient samples within hours after collection.
the Sysmex analyser, Sysmex reagents, Sysmex quality con- Blood cells within quality control material are therefore sta-
trol bloods and Sysmex certified service support. bilised to prevent disintegration with time. Not all cells can
however be stabilised without unacceptable loss of function
Internal quality control using Sysmex quality and therefore sometimes artificial substitutes are used. The
control bloods compatibility of such alternate substitutes will vary from
The primary purpose of quality control is to detect any sys- analyser to analyser depending on the technology used by
tematic errors within the analytical system that may cause each system. There will be a good chance that results may
a wrong patient result to be issued, and consequently a not be comparable if third party materials are used. Moreo-
wrong clinical action to be taken. To ensure reliability of ver, if target values are supplied with third party materials
results, continuous monitoring of the analyser is an absolute there is no guarantee that the results have been thoroughly
requirement. In order to do this effectively, the performance validated on each specific analyser model for each lot num-
of quality control using Sysmex quality control bloods spe- ber. It should also be noted that the use of third party rea-
cific for each class of analyser must be incorporated into gents on a Sysmex analyser invalidates the manufacturer’s
daily routine practice. The Sysmex control bloods listed in performance claims. What this means is that the laboratory
Tab. 2 have been specifically designed for each correspond- will carry full liability in the event of any medico-legal claim
ing instrument in order to thoroughly check the reagent arising from an erroneous test result having been issued.
system and technical system as it pertains to each particu-
lar instrument model.
Control Blood Analyser
XN CHECK XN-Series
Why third party reagents and control material cannot
analysers
be used as substitutes for Sysmex control bloods
It is of paramount importance to strictly adhere to the con-
cept of an analytical system as the technology of measure-
e-CHECK (XE) XE-, XT- and
ment is designed and validated based on the combination
XS-Series
of Sysmex hardware and Sysmex reagents. Although all
analysers
­haematology analysers will generate the same basic results,
the technology used to perform the measurement may dif- e-CHECK (XS) XS-Series
analysers
fer substantially, e.g. Sysmex X-Class analysers utilise fluo-
rescence flow cytometry to perform a differential count
whereas all competitor systems do not. If a third party qual- EIGHTCHECK- XP-300,
ity control is used on an X-Class analyser it is highly likely 3WP pocH-100i
that the differential count may not be reliably measured as and K-Series
analysers
the material would not have been designed and validated
Tab. 2 Sysmex quality control bloods
 SEED Haematology – Internal quality control in haematology– for the sake of the patient 4
Sysmex Educational Enhancement and Development | July 2013

Sysmex quality control blood Which quality control data indicates satisfactory
As indicated in Tab. 2, Sysmex quality control material is spe- ­analyser performance?
cific to the class of analyser. Three levels of control, namely The assay ranges (upper and lower limit) represent the
low (level 1 – red top), normal (level 2 – white top) and high interval of acceptable values. Individual QC results that are
(level 3 – black top) are produced per lot number. The use consistently located in a stable pattern between the upper
of all three levels is recommended to ensure that the per- and lower limits are indicative of satisfactory performance
formance of the analyser is validated across the range of of the analyser. A stable pattern refers to the absence of
expected patient results. Sysmex quality control bloods are trends or shifts of data and that the daily variation between
supplied together with assay data sheets which indicate the individual QC measurements is low. It is a common miscon-
assay mean value and upper and lower limits which deter- ception that QC results must be located on or around the
mine the assay ranges for each parameter (Fig. 2). The assay assay mean. This is not a prerequisite as the assay mean is
mean values are established independently for each lot a reference only and should not be interpreted as the ‘true
number produced and the assay range is calculated using value’. QC data that is consistently either above or below the
the limit (%) values that have been predetermined by the assay mean, but within the target range is judged as good QC
R&D Division of Sysmex Corporation Japan based on the performance. The QC data for each parameter is automati-
results of replicate measurements performed on multiple cally charted on the analyser per lot number, mode and level.
standard analysers and for multiple control blood lots. The
limit (%) values are specific for the control blood, analyser Any sporadic outliers, shifts or trends* should be investigated
type, concentration level, measurement mode and parame- in accordance with the analyser operator manual, QC pack-
ter. These values are used consistently for the calculation of age insert, end-user training received and the laboratories
assay ranges for all lots of a specific control blood. The assay own troubleshooting standard operating procedures. In the
data is supplied as a specific data sheet which is included in event of uncertainty please contact your local Sysmex rep-
the clam shell packaging and/or electronically on a CD-ROM. resentative. The details of this are beyond the scope of this
The benefit of using the electronic data is that it eliminates newsletter.
any transcription errors when uploading new quality control
lot numbers onto an analyser.

EIGHTCHECK-3WP Assay Sheet

Low Level
LOT 3095 0821

13-July-2013

Temperature during Assay 25°C

Model WBC RBC HGB HCT MCV MCH MCHC PLT

10e3/µl 10e6/µl g/dl mmol/l % fl pg fmol g/dl mmol/l 10e3/µl
KX-21 Range 3.5 2.45 6.7 4.2 19.1 80.0 29.2 1809 39.3 24.4 70
XP-Series 1) 2.7 2.21 6.1 3.8 16.1 71.0 25.8 1605 33.5 20.8 38
Mean 3.1 2.33 6.4 4.0 17.6 75.5 27.5 1707 36.4 22.6 54
Limit %
12.0 5.0 5.0 5.0 8.5 6.0 6.0 6.0 8.0 8.0 30
Limit # 0.4 0.12 0.3 0.2 1.5 4.5 1.7 102 2.9 1.8 16
1)
MCH value in amol and not in fmol

Fig. 2 Example of a Sysmex control blood assay data sheet.

*For a few parameters a slight trend over the life time of the control blood is expected. This applies mainly for the parameters that are influenced by the cell volume of the red
blood cells. It is a natural process that red blood cells in blood samples swell over time and this also occurs in control bloods although to a much smaller extent because the
cells in control bloods are stabilised. Therefore the haematocrit (HCT) and the mean cell volume (MCV) very slightly increase over the life time of the control blood while the
mean corpuscular haemoglobin concentration (MCHC) decreases very slightly. As this effect is influenced by the temperature a proper storage of the control blood according
to the package insert is important to minimise its extent.
SEED Haematology – Internal quality control in haematology– for the sake of the patient 5
Sysmex Educational Enhancement and Development | July 2013

When should internal quality control be performed? time specified in the package insert. The cold QC vial must
When and for how many levels internal QC should be per- not be warmed, e.g. within the hands, because the blood cells
formed may be subject to national regulations. The follow- in the QC material can be damaged if they are exposed to a
ing gives some general recommendations. In order to cover high temperature difference. The second step is to mix the
the full clinical spectrum of patient samples that may be QC vial according to the procedure specified for the particu-
encountered it is recommended to process all three levels lar control blood product by end-to-end inversion or by roll-
of QC material on each haematology analyser. If this is not ing between the palms until all cells are resuspended. When
applied at least two levels of QC material should be used. first opening a new vial it is particularly important to ensure
The frequency of QC measurements may vary between once sufficient mixing to resuspend all cells. It is important to
per day (e.g. for one working shift of 8 hours per day) to two understand that the stabilisation of the blood cells within
or three times per day (e.g. for 24 hours operation). If an the QC material influences their properties and therefore
analyser has both an open and a closed mode (e.g. XT- and the QC material needs to be mixed in a different way than
XE-Series analysers) and both modes are used to test patient patient samples and must not be mixed using automatic
samples QC must be performed on both modes. Whenever mixers.
any intervention has occurred on the analytical system such
as a service intervention, or when a technical problem is sus- What are the consequences of not performing
pected and after it has been rectified, additional QC meas- ­appropriate internal quality control on haematology
urements are required. analysers?
The consequences of choosing not to run QC at all, or by
Expiry dates and open vial stability of Sysmex using third party products, or by not rectifying QC errors
quality control bloods that occur are serious as it means that the laboratory will
It is important to adhere to the expiry date and open vial have no means of ensuring that patient results produced
stability of Sysmex quality control bloods. The expiry date during this time are accurate. The patient results may still
of each lot number is clearly printed on each vial and on each be accurate but on the other hand they may not be. In the
assay data sheet. Although lifespan of the blood cells within absence of an objective QC check with rigorous attention
the QC material has been extended through stabilisation, this to troubleshoot and rectify any errors, we can not be sure.
is not indefinite and therefore the material can no longer be Laboratory professionals have an ethical obligation to ensure
guaranteed to perform predictably beyond the expiry date. that every laboratory result issued has been produced under
Likewise, it is important to understand the concept of open rigorous quality control conditions. Doctors consequently
vial stability. Once a QC vial has been pierced by the analyser are justified in their expectation that all laboratory results
needle or has been decapped and exposed to air, the mate- that have been authorised and released by the laboratory
rial starts to slowly deteriorate and performance is only guar- are true. They in turn have an ethical obligation to treat their
anteed if the open vial stability is adhered to. Open vial sta- patients taking all available information under consideration.
bility is 7 days for XN Check, e-Check (XE) and Eightcheck-3WP The laboratory, and not the doctor, will therefore be liable
and 14 days for e-Check (XS). in the event that any deleterious consequences follow on a
clinical decision that was taken in good faith based on an
Handling of Sysmex quality control bloods incorrect laboratory result that was duly authorised by the
It is important to handle Sysmex quality control bloods in laboratory. As it is understandably difficult for laboratory
accordance with the QC package insert and the end-user staff to feel the same connection to patients as there is lit-
training received because incorrect handling can lead to erro- tle of not direct interaction, this message is best illustrated
neous QC results and impairs the quality of your internal QC. through some clinical case studies.
After taking the QC vial out of the refrigerator the first step
is to bring it to room temperature by letting it stand for the
SEED Haematology – Internal quality control in haematology– for the sake of the patient 6
Sysmex Educational Enhancement and Development | July 2013

a) Clinical case study 1: a 4 year old child with acute c) Clinical case study 3: a 2 year old child with mild
leukaemia, currently receiving a cycle of chemo- fever and earache
therapy every 3 weeks ■■ CBC+DIFF reveals a normal WBC and normal NEUT#
■■ CBC+DIFF reveals NEUT# of 0.8 x 10 /L 9
■■ Clinical decision – infection probably viral, send child
■■ Clinical decision – withhold chemotherapy until home
NEUT# rises to above 1 x 10 /L 9
■■ BUT True WBC and NEUT# is actually elevated
■■ BUT True NEUT# was 1.2 x 10 /L 9
­suggesting bacterial infection

The consequence is that by unnecessarily delaying chemo- Consequence is that antibiotics are erroneously withheld.
therapy the chances of remission and possible cure for the The risk is that an untreated bacterial ear infection in a young
child are significantly reduced. child can rapidly spread and become meningitis which in turn
carries a high risk of possible brain damage or even death.
b) Clinical case study 2: female patient with autoim-
mune haemolytic anaemia Take home message
■■ CBC reveals a HGB of 8 g/dL Regular processing of internal quality control using the
■■ Clinical decision – blood transfusion not indicated ­Sysmex quality control bloods that are appropriate for each
■■ BUT True HGB is actually 6 g/dL specific Sysmex analyser and conscientious monitoring of
the performance of each parameter, on all modes (if appro-
Consequence of erroneously withholding blood transfusion priate) using all levels (or at least 2 of the 3) is an absolute
is that the patient may become seriously compromised and non-negotiable requirement for any laboratory to be able
develop multi-organ failure needing intensive care unit to issue results in order to enable doctors to make mean-
admission at major cost! ingful and safe clinical decisions for all patients entrusted
into their care.

Sysmex Europe GmbH

Bornbarch 1, 22848 Norderstedt, Germany, Phone +49 40 52726-0 · Fax +49 40 52726-100 · [email protected] · www.sysmex-europe.com