Int J Lab Hematology - 2014 - Bourner - ICSH guidelines for the verification and performance of automated cell counters for (1)

International Journal of Laboratory Hematology
The Official journal of the International Society for Laboratory Hematology
ORIGINAL ARTICLE
INTERNAT IONAL JOURNAL OF LABORATO RY HEMATO LOGY
ICSH guidelines for the verification and performance of
automated cell counters for body fluids
G. BOURNER*, B. DE LA SALLE † , T. GEORGE ‡ , Y. TABE § , ¶ , H. BAUM**, N. CULP † † , T. B. KENG ‡ ‡ ,
ON BEHALF OF THE INTERNATIONAL COMMITTEE FOR STANDARDIZATION IN HEMATOLOGY (ICSH)
*Gamma Dynacare Medical
Laboratories, Brampton, ON,
Canada
†
UK National External Quality
Assessment Scheme for General
Haematology, Watford, UK
‡
Department of Pathology,
University of New Mexico,
Albuquerque, NM, USA
§
Department of Clinical
Laboratory Medicine, Juntendo
University School of Medicine,
Toyko, Japan
¶
Japanese Society for Laboratory
Hematology, Standardization
committee, Tokyo, Japan
**Institut f€
ur
Laboratoriumsmedizin,
Regionale Kliniken Holding
RKH GmbH, Ludwigsburg,
Germany
††
Trillium Diagnostics, Bangor,
ME, USA
‡‡
Sullivan Nicolaides Pathology,
Brisbane, QLD, Australia
Correspondence:
Gini Bourner, Gamma Dynacare
Medical Laboratories, 115 Midair Ct., Brampton, ON, Canada
L6T 5M3. Tel.: +01 905 790
3515, ext. 5220;
Fax: +01 905 790 2990;
E-mail: [email protected]
S U M M A RY
One of the many challenges facing laboratories is the verification of
their automated Complete Blood Count cell counters for the enumeration of body fluids. These analyzers offer improved accuracy,
precision, and efficiency in performing the enumeration of cells compared with manual methods. A patterns of practice survey was distributed to laboratories that participate in proficiency testing in
Ontario, Canada, the United States, the United Kingdom, and Japan
to determine the number of laboratories that are testing body fluids
on automated analyzers and the performance specifications that
were performed. Based on the results of this questionnaire, an International Working Group for the Verification and Performance of
Automated Cell Counters for Body Fluids was formed by the International Council for Standardization in Hematology (ICSH) to prepare a
set of guidelines to help laboratories plan and execute the verification of their automated cell counters to provide accurate and reliable
results for automated body fluid counts. These guidelines were discussed at the ICSH General Assemblies and reviewed by an international panel of experts to achieve further consensus.
doi:10.1111/ijlh.12196
Received 1 December 2013;
accepted for publication
2 January 2014
Keywords
Automated cell counts, body
fluids, cerebrospinal fluid,
verification
598
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 598–612
INTRODUCTION
fluid analysis, to laboratories in the United States that
participate in the College of American Pathologists
(CAP), to the laboratories in the United Kingdom that
participate in the National External Quality Assessment Service for General Hematology [UK-NEQAS
(H)], and to the laboratories that participate in the
Japanese Society of Laboratory Hematology (JSLH)
proficiency testing program.
The purpose of the questionnaire was to determine
whether laboratories were using automated methods
for cerebrospinal fluid (CSF) cell counts and other
body fluid cell counts and how the performance specifications were determined for these analyzers. The
details of the patterns of practice can be found in
Appendix 1 of this document.
Laboratories were asked to indicate the performance qualifications that were carried out to determine whether the analyzer was acceptable to meet
quality requirements for the enumeration of body
fluids.
Figure 1 shows the percentage of laboratories that
performed accuracy and precision. A wide range of
laboratories performed precision (19–83%), accuracy
(26–86%), sensitivity (11–64%), specificity (5–33%),
and reportable range (2–71%). Fewer laboratories
performed studies to evaluate sensitivity, specificity,
and reportable range compared with precision and
accuracy. North American laboratories performed
these performance qualifications more frequently than
laboratories in the United Kingdom and Japan.
The laboratories were also asked questions as to
what protocols they had established to determine the
The intended purpose of this guideline is to provide
recommendations for the verification of automated
cell counters for the accurate enumeration of cells in
body fluids. Multiple analyzers are available on the
markets today that offer automated solutions to performing enumerations of cells in body fluids. Manual
counting is labor intensive, lacks reproducibility, and
requires a high level of expertise. Many laboratories
already perform automated counts or have started to
verify their systems. Numerous articles have been
published [1–7], but in many cases, the verification is
incomplete. In a few cases, the articles include studies
on analyzers that the manufacturer provided no performance specifications [2]; therefore, it becomes the
responsibility of the laboratory to perform a complete
validation as opposed to verification. A working group
was formed by the International Council for Standardization in Hematology (ICSH) to prepare a set of
guidelines to help laboratories plan and execute the
verification of their automated cell counters to provide accurate and reliable results for automated body
fluid counts.
Current laboratory practices
A patterns of practice questionnaire was developed
by the Quality Management Proficiency–Laboratory
Services (QMP-LS) of Ontario, Canada. This was distributed to laboratories in Ontario that participate in
the QMP-LS external proficiency program for body
100
Percentage of laboratories
Figure 1. Testing performed for
validation studies.
UK-NEQAS
JSLH
QMP-LS
CAP
90
599
86
83
75
80
71
70
64
60
60
50
43
47
43
36
40
26
30
20
29
25
33
19
11
14
11
5
10
2
0
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 598–612
Precision
Accuracy
Sensitivity
Specificity
Report range
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G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
quality of their results. These protocols included
whether the laboratories ran body fluid control samples, performed background counts prior to running a
sample, and had protocols to handle spurious results.
The results are shown in Figure 2. One notable observation is that few laboratories use a separate body
fluid control.
Most of the new analyzers on the market have a
body fluid mode, but it is important that the manufacturer’s performance claim is verified for each type of
body fluid that is to be run including CSF, serous fluids (pericardial, pleural, ascitic), and synovial fluids. It
is particularly important that it is shown that the
analyzer can provide accurate counts at the low levels
which are more often found in the different body
fluids, particularly CSF [8].
VA L I DAT I O N / V E R I F I C AT I O N O F AU TO M AT E D
S YS T E M S
It is important for laboratories to understand the
difference between validation and verification. Validation is usually carried out by the manufacturer and
provides the performance characteristics of a method.
If validation has not been carried out by the manufacturer, then it must be carried out by the laboratory.
Validations performed by the laboratory should follow
any local guidelines and recommendations for establishing a laboratory-developed test (LDT) [8].
Verification is a confirmation of the validation performed by the manufacturer that provides evidence
that the analyzer can meet specific requirements within
a given test site. This verification must be carried out
by the each individual laboratory before the analyzer is
used for testing. Verification or a transference verification (described below) must be performed on each individual analyzer that will be used for testing clinical
samples. The recommendations in this guideline are for
the verification of a manufacturer’s claim.
Manufacturer’s intended use
Manufacturers are required to have a statement of
intended use, which indicates the type of body fluids
that have been validated on the analyzer. The analytical measurement range (AMR) for each type of body
fluid is provided by the vendor in the specifications. It
is the laboratory’s responsibility to be aware of this
statement. If the laboratory’s intent is to run other
fluids that are not included in the manufacturer’s
claim, then the performance of the analyzer for
counting these fluids must be validated as this is considered a LDT.
The hematology analyzers most commonly used to
perform body fluid enumeration are listed in Table 1
with the fluids and parameters that have been validated by the manufacturers.
Specimen handling—pre-analytic variables
QMP-LS
CAP
UK-NEQAS
JSLH
100
86
Percent of laboratories
90
82
79
75
80
82
67
70
60
54
50
37
40
40
Sample stability
30
20
10
Laboratories should be aware of the pre-analytic variables during specimen collection, including the type
of container, transportation, and storage that can have
an effect on the reportable result [8]. Each laboratory
must have a standardized operating procedure that
follows recommended guidelines for their locale. This
point is beyond the scope of this document.
19
10 8
0
Controls
Background each test
Spurious results
Figure 2. Use of body fluid controls, background
count, and spurious results in laboratories surveyed.
It is well documented that cellular deterioration, cell
lysis, and bacteria growth can occur within hours of
specimen collection, depending on the time elapsed,
storage conditions, and type of sample [8]. Sample
testing should occur within the time the sample
remains stable, and the correlation between methods
should be within 2 h of each other [9].
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600
601
Table 1. List of hematology analyzers most commonly used to perform automated body fluid counts
Analyzers
Fluids
Beckman LH 750/780
Beckman DxH 800
Sysmex XE 2100, XT 1800i/2000i,
Sysmex XT-4000 and XE-5000
Serous,
Serous,
Serous,
Serous,
Advia 2120, 2120i
Peritoneal, pleural, peritoneal dialysate
CSF
CSF, pleural, peritoneal, peritoneal lavage,
peritoneal dialysate, pericardial, synovial,
general serous
Iris iQ200 and iRICELL systems
Parameters reported
synovial,
synovial,
synovial,
synovial,
cerebrospinal fluid (CSF)
CSF
CSF
CSF
Performance specifications
It is good laboratory practice to provide evidence that
the analyzer is capable of reporting reliable results;
this is a regulatory requirement in some countries [8,
10]. Body fluids have a different matrix than whole
blood and may contain different cell types compared
with peripheral blood. Therefore, it is critical to
ensure that the analyzer produces true and reliable
results for each body fluid type that the laboratory is
intending to analyze [8]. Peripheral blood samples
should not be used for validation or verification.
Many analyzers have a dedicated body fluid mode;
therefore, the verification of the complete blood
count (CBC) does not satisfy regulatory requirements
for body fluid reporting. Each laboratory needs to
determine its own goals of acceptability, with a performance specification study.
A full verification may be performed on one analyzer at one site for laboratories with multiple analyzers or laboratories that are part of a large group such
as an integrated health network. A transference verification can be performed on the other analyzers,
providing the instruments are from the same manufacturer and are the same model [11]. This means that
a full study does not need to be performed, but the
data from the full verification need to be available at
the other sites for laboratory accreditation purposes.
Table 2 shows what studies should be performed for a
full and a transference verification. For example, the
patient correlation full validation may be carried out
with 40 samples, but the transference can be carried
out with 20 samples. Samples may be shared among
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 598–612
WBC, RBC {WBC = TNC}
TNC, RBC
WBC, RBC
BF Mode:WBC-BF, TC-BF, RBC-BF,
2 part diff (mononuclear/
polymorphonuclear)
TNC, RBC
TNC, RBC, 5 part diff and PMN/MN%
Nucleated count, RBC
Table 2. Full verification vs. transference
Studies
Precision (repeatability)
Accuracy
Analytical sensitivity
Analytical specificity
in include interfering
substances
Reference range
Patient correlation
studies
Linearity
Limits of detection
Carryover
Analytical measuring
range
Full
verification
Transference
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Full study
Full study
Smaller study
Smaller study
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
sites, as long as the integrity of the sample can be
maintained during transportation of the samples.
Accuracy (Trueness)
Accuracy or trueness can be verified using two different approaches [12].
• Comparability can be performed using split sample
testing, usually with a minimum of 40 patient samples
distributed evenly over the reporting range. The
results are compared against the laboratory’s defined
limits to determine whether significant differences
occur. This can be challenging where manual counting is the comparative method.
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G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
•
Recovery of expected values from assayed reference
materials such as commercial controls may also be
used. The laboratory should set its own limits for the
acceptable range.
Precision (Repeatability)
The precision of the analyzer must be assessed in a
way that takes into account all of the variables that
may influence the analyzer [13]. It is important that
the test samples have the same characteristics as clinical samples. It is recommended to test two or more
concentrations, usually a high and low concentration,
including a sample at any medical decision point(s). It
is recommended that the samples should be run a
minimum of 10 times to determine within-run precision [13]. Depending on the volume of available sample, it may be difficult to run 10 times, but at least
five runs should be performed for valid statistics.
Reproducibility should also be determined over a
period of time. Due to the instability of the samples, it
is not possible to run the same sample on different
days, but the precision study may be performed with
an automated body fluid control.
recommended that the manual counting be carried
out in duplicate to improve the precision of manual
counting [8]. The stability of the sample should be
taken into account. Samples should be stored under
the same conditions and tested within 2 h of each
other to avoid sample storage as a variable.
Carryover
It is important to ensure that a high sample does not
cause a positive bias on the following sample and
cause a false high result [10]. This is particularly true
for CSF samples. As it is recommended that a blank
is run prior to running a body fluid sample, it is
equally important to ensure that a nonblood aspiration prior to the analysis of the body fluid sample
should not cause a dilution and a false low result
[10].
Testing should be carried out using a fluid with an
elevated count followed by a sample with a low
count. The high sample should be run three times,
A1, A2, and A3, followed by the a low sample run
three times B1, B2, and B3. The carryover is calculated using the following equation:
% Carryover ¼
Patient correlation
Samples should be handled and testing performed
according to accepted laboratory protocol and the
manufacturer’s recommendations. Studies may be
performed either using the laboratory’s current
method, the method used by the manufacturer in
their claim or a reference method [10]. It should be
noted that the predicate used for validation by vendors in most cases is the manual count.
It is recommended that a minimum of at least 40
samples should be tested and samples should be
included that cover the analytical range, particularly
at medical decision levels [9]. Correlation should be
performed with each fluid type. Body fluid counts
with low and high values are necessary to determine
the bias at the limits of the analytical measurement
range. This may be difficult for smaller laboratories,
but the more samples, the better the correlation data
and the greater the opportunity to challenge the system samples with interfering substances. If the reference method is the manual cell counting method, it is
B1 B3
100
A3 B3
As some laboratories run a blank sample prior to
analyzing a body fluid, it is also important to ensure
that this does not cause a false low result due to a
predilution [10].
If the carryover is unacceptable based on your laboratories acceptability, maintenance or service may be
required and the carryover study should then be
repeated.
Lower limits of detection
This is probably one of the most critical verifications
steps, particularly in the analysis of CSF cell counts.
The lower limits must be defined for both total
nucleated cells and erythrocytes and should not
exceed the limits suggested by manufacturers [8,
14]. The verification should be carried out with all
fluid types that the laboratory intends to analyze, to
account for the matrix effect of the samples [8]. For
verification, it is not necessary to use different
reagent lot numbers.
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602
It is important to understand the different limits of
lower levels and their relationship [14].
Limit of blank (LOB) is the highest measurement
that should be obtained with a blank sample. The
LOB is determined running repeated measurements
on multiple blank samples
Limit of detection (LOD) or analytical sensitivity is
the lowest measurement of an analyte that can be
detected in a sample. This is carried out by repeat
testing on at least four to six samples with low concentration cell counts that are usually within the
range of the LOB to four times the LOB [14].
Limit of quantitation (LOQ) is the lowest measurement of an analyte in a sample that can be
detected with acceptable precision and trueness.
This must meet your laboratory’s requirement for
accuracy or total allowable error.
The
relationship
between
the
limits
is
LOB < LOD < LOQ. The limits of detection and limits
of quantitation are quite often the same value, but
must be higher than the limits of blank [14].
How to verify a claimed LOB and LOD
The LOB is determined using replicate analysis of
more than one different type of fluid without any
cells if possible. It is recommended to use body fluids
to avoid matrix effects, but if it is not possible to use
body fluid samples, diluent may be used. Each sample
should be run a minimum of 10 times. The study
should be performed on at least two or three different
days to take into account different laboratory conditions. Depending on the availability of the samples, it
is not necessary that this be performed on consecutive
days. If a minimum of three of the replicate analysis
are equal to or less than the manufacturer’s LOB, it is
acceptable to use the manufacturer’s claimed LOB, if
the manufacturer has specified the LOB.
The LOD is determined using the same process
with samples with a low concentration equivalent to
the manufacturer’s claimed LOD, if the manufacturer
has specified the LOD. If the results are within 95%
agreement, then the manufacturer’s claimed LOD
may be used [14]. Otherwise, the laboratory must
establish their own LOD [14].
The LOQ needs to be performed whether the
observed precision of the LOD does not meet the
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 598–612
603
laboratory’s acceptable set goals for precision. The
same process would be used to determine the LOQ
[14].
The LOD or LOQ is the lowest cell count that is
reliably detected and meets the laboratory’s goal of
uncertainty, that is, the bias and imprecision.
Analytical specificity to include interferences
Manufacturers should identify any interfering substances that may lead to erroneous results. Interfering substances in body fluids can be anything from
small clots to crystals, and the laboratory should
access what effect these interfering substances have
on the results.
The study should be defined in advance to take
into account the laboratory’s specific patient population. It should include all types of body fluids, including those with interfering substances and from those
patients with various disease states [8]. This study is
can be included with the patient correlation.
Analytical measurement range, linearity
The analytical measurement range is the range of the
cell counts that the analyzer can accurately measure
without any pretreatment such as a dilution. The
study should be carried out with samples of similar
matrix compared with body fluids [10, 15]; therefore,
the recommendation is to perform the linearity for
each type of body fluid that the laboratory intends to
run on the analyzer [8].
The manufacturer must define the AMR; it is the
responsibility of the laboratory to verify this claim.
This is demonstrated by testing 5–7 concentrations
throughout the stated linear range. Three replicates
should be tested at 4–6 levels of concentrations [15].
The diluent to be used should be recommended by
the manufacturer. It is important to use concentrations of cell counts at medical decision points, at the
maximum concentration, and at the lower limit of
detection, particularly for CSF samples.
It may be difficult to find a sample with high values during the verification period. The linearity may
be repeated at a later time if a higher sample is
received and laboratory protocol updated to reflect
the higher upper limit.
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G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
Limited number of samples
The biggest hurdle probably facing most laboratories is
the availability of samples to perform the verification
or validation studies. Once the decision is made to
run automated body fluid counts, data collection can
be integrated into the daily routine. Each time a
sample is received, it should be tested with both
methods, the current method and the method under
verification, and the data saved for later statistical
comparison. The accumulated data should be
reviewed periodically to ensure that all fluid types
have been verified and to identify where the correlation is poor, looking for common causes between the
samples.
The number of samples required to perform the
studies will be difficult for smaller laboratories. It is
important to have enough samples to obtain valid statistics and to ensure that the analyzer is providing
true results, especially at medical decision points. This
question was asked in the patterns of practice questionnaire and laboratories used anywhere from 1 to
10 samples, even greater than 80 samples. For valid
statistics, it is recommended to perform studies using
a minimum of 40 samples per sample type [9].
If the samples are run through an open mode, it is
good laboratory practice to clean the outside of the
probe as well. The background count must equal to or
be less than the lower limit of blank. If not, it should
be repeated. If the count is still high after the repeat,
then the instrument should be put through a cleaning
cycle or daily maintenance.
Procedures for handling spurious results
Most systems have flags that indicate when the result
should not be accepted without further review. Laboratory procedures should have instructions on how to
investigate these flags and the actions required when
they occur with body fluid samples [8]. These procedures should include how to detect debris or cell
clumps that may cause spurious results and indicate if
it is necessary to use an alternative counting method.
The investigation may be a macroscopic examination
or microscopic examination by a wet preparation. If
the policy of the laboratory is to perform testing in
the samples that are considered irretrievable, then the
laboratory report should include a description of these
findings and the impact on the accuracy of the
results.
A N A LYS I S O F AU TO M AT E D B O DY F L U I D S
Procedure if results outside reportable range
The automated counting of body fluid samples
requires different handling procedures from peripheral
blood samples. Standard operating procedures should
include all steps required for handling the sample,
changing modes on the analyzer, and running the
sample.
The laboratory must define the upper and lower
reporting limits for each fluid when the results are
outside the analytical measuring range verified by the
laboratory (Section Analytical measurement range,
linearity). There should be a written protocol for
handling samples that exceed both the upper and
lower limits of the reporting range including a procedure for performing a dilution if the result exceeds
the AMR [8].
Treatment of sample prior to running
The manufacturer’s statement of intended use must
state if any special treatment for a sample is necessary
before analysis. One example would be the pretreatment of synovial fluid samples with hyaluronidase to
reduce viscosity of the samples.
Background check
Before running any samples, particularly CSF samples,
it is important to make sure that the aspiration pathway is clean to avoid any contamination of the fluid.
Units of measure
Laboratories were asked to indicate the units of
measure used to report body fluid cell counts, and the
survey results showed that different units of measure
are used which can be found in Appendix 1. This can
be confusing to the physician. It is recommended that
for automated body fluid counts, the same units of
measure should be used as for the CBC. This also
eliminates the need for a calculation which may result
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604
in an erroneous result. The units of measure used
should be clearly stated on the patient’s report.
Q UA L I T Y C O N T R O L
605
your laboratory from an external proficiency program,
then proficiency must be demonstrated by other
means such as blind testing or interlaboratory sample
exchange and comparison to meet regulatory compliance.
Internal quality control
The analytical system must be controlled for the
quantitation of body fluid samples. Commercial body
fluid controls are available, but there has been some
confusion whether it is necessary to run a separate
control or whether the daily commercial CBC control
is acceptable. Newer analyzers have specific body fluid
modes, and it is important to understand whether this
mode is a different channel, aspiration pathway, sample dilution, reporting mode, counting volume, or cell
analysis compared with the CBC mode. If the body
fluid samples are tested differently, a separate control
is necessary. Commercial products are also available
that test the analyzer in the lower end of the AMR of
body fluids.
Other considerations should be if the differential is
being reported from the analyzer. Some analyzers
report a two-part differential, which is included as
part of the body fluid commercial controls.
Proficiency testing
Proficiency testing is a requirement for laboratory
accreditation. If testing samples are not available to
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7. Danise P, Maconi M, Rovetti A, Avino D,
Di Palma A, Gerardo Pirofalo M, Esposito
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between three automated haematology
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method. Int J Lab Hematol 2013;35:
608–13.
8. Clinical Laboratory Standards Institute
(CLSI). Body Fluid Analysis for Cellular
Composition. Approved Guideline: CLSI
Document H56-A, (ISBN 1-56238-614-X),
CLSI, 940 West Valley Road, Suite 1400,
Wayne, PA, 19087 USA, June 2006.
9. Clinical Laboratory Standards Institute
(CLSI). Method comparison and bias Estimation Using Patient Samples: Approved
Guideline, 2nd edn. CLSI document EP9A2 (ISBN 1-56238-472-4). CLSI 940 West
Valley Road, Suite 1400, Wayne, PA,
19087 USA, 2002
10. Clinical Laboratory Standards Institute
(CLSI). Validation, Verification, and Qual-
1751553x, 2014, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/ijlh.12196 by Cochrane Peru, Wiley Online Library on [07/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
Precision and Trueness Approved Guideline, 2nd edn. CLSI document EP15-A2
(ISBN1-56238-574-7). CLSI, 940 West Valley Road, Suite 1400, Wayne, PA, 19087
USA, 2005.
13. Clinical Laboratory Standards Institute
(CLSI). Evaluation of Precision Performance of Quantitative Measurement
Methods; Approved Guideline, 2nd edn.
CLSI document EP5-A2 (ISBN1-56238542-9). CLSI, 940 West Valley Road,
Suite 1400, Wayne, PA, 19087 USA,
2004.
14. Clinical Laboratory Standards Institute
(CLSI). Evaluation of Detection Capability
ity Assurance of Automated Hematology
Analyzers; Approved Guideline, 2nd edn.
CLSI document H26-A2 (ISBN 1-56238728-6). CLSI, 940 West Valley Road,
Suite 1400, Wayne, PA, 19087 USA,
2010.
11. Clinical Laboratory Standards Institute
(CLSI). Defining, Establishing, and Verifying Reference ranges in the Clinical Laboratory Approved Guideline, 3rd edn. CLSI
document C28-A3 (ISBN1-56238-682-4).
CLSI, 940 West Valley Road, Suite 1400,
Wayne, PA, 19087 USA, 2005.
12. Clinical Laboratory Standards Institute
(CLSI). User Verification of Performance for
for Clinical Laboratory Measurement Procedures; Approved Guideline, 2nd edn. CLSI
document EP17-A2 (ISBN1-56238-795-2
[print]; ISBN1-56238-796-0 [electronic]).
CLSI, 940 West Valley Road, Suite 1400,
Wayne, PA, 19087 USA, 2012.
15. Clinical Laboratory Standards Institute
(CLSI). Evaluation of the Linearity of
Quantitative Measurement Procedures: A
Statistical Approach; Approved Guideline.
CLSI document EP6-A (ISBN1-56238-4988). CLSI, 940 West Valley Road, Suite
1400, Wayne, PA, 19087 USA, 2003.
APPENDIX
Patterns of practice with summary of responses
The patterns of practice survey were distributed to laboratories in Ontario that participate in the QMP-LS external proficiency program for body fluid analysis, to laboratories in the United States that participate in the College
of American Pathologists (CAP), to the laboratories in the United Kingdom that participate in the National External Quality Assessment Service for General Hematology [UK-NEQAS (H)], and to the laboratories that participate
in the Japanese Society of Laboratory Hematology (JSLH) proficiency testing program. The questions and
answers are summarized below.
1. Does your laboratory perform automated body fluid counts (e.g., cerebrospinal fluid (CSF) or ‘other’ body fluids
including synovial, pleural, peritoneal, or any other body fluid) on an electronic hematology analyzer?
Laboratories
Laboratories
Laboratories
Laboratories
that received survey
that responded
performing automated body fluid counts
performing automated CSF counts
QMP-LS
CAP
UK-NEQAS (H)
JSLH
130
129 (99%)
58 (45%)
5 (4%)
1042
396 (38%)
291 (73%)
241 (61%)
608
234 (38%)
49 (21%)
17 (7%)
273
122 (45%)
60 (49%)
25 (20%)
2. How many automated CSF cell counts does your laboratory perform per month?
Number of CSF
samples per month
QMP-LS
n=5
CAP
n = 241
UK-NEQAS
n = 16
JSLH
n = 32
1–10
11–20
21–40
41–80
81–100
>100
Only if grossly bloody
1–2 per year
2
1
128
43
27
30
4
9
10
3
2
7
8
8
7
1
1
1
1
1
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 598–612
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606
607
3. How many automated ‘other’ body fluids cell counts does your laboratory perform per month?
Number of other body
fluid samples per month
QMP-LS
n = 57
CAP
n = 291
UK-NEQAS
n = 46
JSLH
n = 54
1–10
11–20
21–40
41–80
81–100
>100
<10 per year
17
12
15
12
65
76
70
43
15
22
25
4
8
4
1
1
3
16
16
10
7
4
1
1
4. What analyzer(s) does your laboratory use to perform automated body fluid cell counts?
QMP-LS
n = 61
Group of analyzers
Abbott Cell-Dyn 3200, Ruby
Abbott Cell-Dyn 3500, 3700
Abbott Cell-Dyn 4000/Sapphire
Abbott Cell-Dyn 1700
Beckman Diff2
Beckman LH 700 Series/DxH 800
Beckman 500 Series
Beckman STKS, MaxM, HmX
Beckman GenS
Sysmex XE-2100
Sysmex XE 5000
Sysmex XT-2000i/XS-1000i
Sysmex XT 4000
Siemens ADVIA 120/2120
Iris iQ200
Pentra ABX
Automated image analysis system
Other
9
4
4
1
1
27
4
2
2
3
CAP
n = 357
UK-NEQAS
n = 53
JSLH
n = 67
1
137
2
2
14
1
7
1
1
14
2
4
61
65
22
6
18
44
2
2
14
23
4
13
1
1
1
8
3
7
5. Is/are the analyzer(s) used to perform automated body fluid cell counts approved by the appropriate regulatory
body, that is, FDA, Health Canada, CE, Japan Ministry of Health?
QMP-LS (%)
n = 58
Yes
No
Don’t know
55
38
7
*CAP—Question not included in survey to participants.
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 598–612
CAP (%)
N\A*
UK-NEQAS (%)
n = 49
JSLH (%)
n = 61
35
14
51
18
48
34
1751553x, 2014, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/ijlh.12196 by Cochrane Peru, Wiley Online Library on [07/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
6. Does the manufacturer have a statement of Intended Use for the analyzer(s) that clearly defines which body fluids
have been approved by a regulatory agency for automated body fluid cell count testing?
QMP-LS (%)
n = 58
Yes
No
Do not know
CAP (%)
N/A*
57
33
10
UK-NEQAS (%)
n = 47
JSLH (%)
n = 57
40
4
56
10
54
36
*CAP—Question not included in survey to participants.
7. If your laboratory uses an approved analyzer for body fluid cell counts, which of the following test system
performance specifications did your laboratory verify/validate/establish prior to testing?
QMP-LS (%)*
n = 32
Did not perform verification study
Accuracy
Precision
Analytical sensitivity
Analytical specificity to include
interfering substances
Reportable range
Reference range study
Other
Correlation studies
Carryover
Linearity
Limits of detection
Not applicable
CAP (%)*
n = 291
UK-NEQAS (%)*
n = 39
JSLH (%)*
n = 66
6
94
84
31
13
4
86
83
64
33
26
31
23
21
5
36
26
19
11
5
50
6
71
37
7
Yes
Yes
Yes
5
3
2
13
6
9
3
41
*Multiple responses received.
8. If your laboratory modified an approved test system or uses an analyzer in which performance specifications are
not provided by the manufacturer, which of the following test system performance specifications did your laboratory
establish/validate prior to testing?
QMP-LS (%)*
n = 26
Did not perform verification study
Accuracy
Precision
Analytical sensitivity
Analytical specificity to include
interfering substances
Reportable range
Reference range study
Other
Correlation studies
Carryover
Linearity
Limits of detection
31
54
31
42
15
42
15
CAP (%)*
n = 13
77
85
69
31
69
31
15
Yes
Yes
UK-NEQAS (%)*
n = 28
JSLH (%)
N/A
17
17
7
7
10
5
N/A
4
4
*Multiple responses received.
JSLH—Question not included in survey to participants.
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 598–612
1751553x, 2014, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/ijlh.12196 by Cochrane Peru, Wiley Online Library on [07/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
608
609
9. How many CSF samples were used for your laboratory’s performance specification study?
Number of CSF samples
Perform automated counts,
but did not perform study
1–10
11–20
21–40
41–80
81–100
>100
QMP-LS
n=5
CAP
n = 160
1
3
1
44
53
38
22
1
2
UK-NEQAS
n = 13
JSLH
n = 21
7
3
2
1
3
5
3
4
2
1
1
2
10. How many ‘other’ body fluid samples were used for your laboratory’s performance
specification study?
QMP-LS
n = 56
Number of other body fluid samples
Perform automated counts,
but did not perform study
1–10
11–20
21–40
41–80
81–100
>100 samples
Commercial BF controls
CAP
n = 214
10
2
12
8
19
1
2
2
UK-NEQAS (%)
n = 41
JSLH
n = 52
28
38
3
2
3
1
4
0
1
3
6
2
1
1
31
67
62
44
6
4
11. What is your laboratory’s reportable range (lower and upper limits) for automated CSF cell counts for the total
nucleated count (TNC)?
Reportable range
Established lower/upper limits
No lower Limit (<)
No upper limit
No upper limit, perform dilution
Laboratories with same limit
Lower limit = 0
Indicated not applicable
Not defined
QMP-LS
n=4
CAP
n = 152*
UK-NEQAS
n=9
1
1
62
5
30
7
14
45
5
2
1
3
2
Note: Laboratories using the same limit indicated that manufacturer’s limits were used.
Some laboratories counted in two categories.
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 598–612
JSLH
n = 13
7
1
2
2
8
1751553x, 2014, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/ijlh.12196 by Cochrane Peru, Wiley Online Library on [07/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
12. What is your laboratory’s reportable range (lower and upper limits) for automated ‘other’ body fluid cell counts
for total nucleated counts (TNC)?
Reportable range
Established upper/lower limits
No lower Limit(<)
No upper limit
No upper limit stated, indicate would perform dilution
Laboratories with same limit
Lower limit = 0
Indicated upper limit not applicable
Not defined
QMP-LS
n = 52
CAP
n = 186
UK-NEQAS
n = 20
JSLH
n = 32
38
4
5
7
22
6
60
15
2
3
2
6
15
36
15
41
5
5
1
8
1
12
Note: Laboratories using the same limit indicated that manufacturer’s limits were used.
Some laboratories counted in 2 categories.
13. What unit value does your laboratory use to report automated CSF cell counts?
Unit value
TNC
RBC
106/L
109/L
/lL
Other
106/L
109/L
1012/L
/lL
QMP-LS
n = 5*
CAP N/A
5
0
UK-NEQAS
n = 16
JSLH
n = 22
2
13
3
2
17
1
4
1
8
7
1
Did not respond
3
1
11
7
CAP—Question not included in survey to participants.
14. What unit value does your laboratory use to report automated ‘other’ body fluid cell counts?
Unit value
TNC
RBC
Did not response
106/L
109/L
/lL
1012/L
Other
106/L
109/L
1012/L
/lL
QMP-LS
n = 59
UK-NEQAS
n = 39
JSLH
n = 57
33
26
10
26
8
7
42
15
3
23
2
1
2
6
21
18
10
CAP N/A*
1
3
5
23
25
*CAP—Question not included in survey to participants.
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 598–612
1751553x, 2014, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/ijlh.12196 by Cochrane Peru, Wiley Online Library on [07/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
610
611
15. Do you run quality control samples for automated body fluid cell counts?
Yes
No
Use CBC control
QMP-LS (%)
n = 58
CAP (%)
n = 256
UK-NEQAS (%)
n = 49
JSLH (%)
n = 62
19
81
82
13
5
10
90
8
92
16. If yes to Question 15, how often?
Each test
Daily
Each shift
Weekly
Other
No response
QMP-LS
n = 11
CAP
n = 222
UK-NEQAS
n=4
JSLH
n=4
5
6
17
75
77
1
52
2
1
4
1
17. If yes to Question 15, what type of QC is used?
Type of control
QMP-LS (%)
n = 11
CAP (%)
n = 246
UK-NEQAS (%)
n=5
JSLH (%)
n=6
Commercial
In-house
55
45
96
4
100
83
17
18. Do you perform background counts prior to automated body fluid cell count analysis?
Yes
No
QMP-LS (%)
n = 58
CAP (%)
n = 259
UK-NEQAS (%)
n = 49
JSLH (%)
n = 62
91
9
100
0
51
49
55
45
19. If yes to Question 18, how often do you perform background counts?
Each test
Daily
Each shift
Weekly
Other
Did not provide response
QMP-LS
n = 58
CAP
n = 100
UK-NEQAS
n = 24
50
4
82
12
2
1
3
18
4
1
4
JSLH—Question not included in survey to participants.
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 598–612
1
JSLH N/A
1751553x, 2014, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/ijlh.12196 by Cochrane Peru, Wiley Online Library on [07/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
G. BOURNER ET AL. | VERIFICATION OF CBC ANALYZERS FOR BODY FLUIDS
20. If yes to Question 17, what is an acceptable background count for total nucleated cells?
Accept background of ‘0’
1/lL
Indicated N/A
QMP-LS
n = 58
CAP
n = 108
UK-NEQAS
n = 18
JSLH
n = 14
14
13
3
10
4
2
1
21. Do you have a procedure for detecting clumps of cells or debris that could lead to spurious results?
Yes
No
Unsure
QMP-LS (%)
n = 58
CAP (%)
n = 256
UK-NEQAS (%)
n = 48
JSLH (%)
n = 56
79
21
82
7
11
40
60
55
45
22. Are you enrolled in a formal EQA program for automated body fluid cell counts?
Yes
No
QMP-LS (%)
n = 58
CAP (%)
n = 291
UK-NEQAS (%)
n = 48
JSLH (%)
n = 60
17
83
94
6
2
98
0
100
23. What are the EQA programs or in-house program do you participate in:
a.
b.
c.
d.
e.
f.
g.
h.
i.
CAP
American Proficiency Institute
UK-NEQAS
No program available in Japan
Split sample testing (manual vs. automated)
Split sample testing with another laboratory
Competency of staff
Commercial QC material
Other
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 598–612
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612