Hematology

Introduction

Blood is very different from other body tissue. Your blood is made of a solid and a liquid portion. The liquid portion is called plasma. The solid portion is comprised of cells. Cells are the basic units of life. All living organisms are made of one or many cells. Unicellular organisms like bacteria are made of just one cell. Multicellular organisms, like plants and animals, are made of more than one cell. The human body has over 75 trillion cells! Cells are so small they must be studied under a microscope to be seen. Bacteria are prokaryotic cells that have no nucleus. Most other living things are made of eukaryotic cells, which have a nucleus and organelles. Organelles are organized structures found in or on cells. The nucleus, the largest organelle, contains chromosomes and stores all the genetic information for the cell. Other organelles make proteins, produce energy, or store wastes. Most organelles are surrounded by membranes that let some substances into the cell while keeping others out. Each cell has a cytoskeleton that gives it shape and may help it move. The cell's cytoplasm (cytosol) surrounds the nucleus and organelles. The entire cell is surrounded by a plasma membrane, which works like the organelle membranes, letting some substances in and keeping others out. The ability to select what comes into the cell is known as being semi-permeable.

Most cells share these basic common characteristics, but in multicellular organisms (like people) each cell also performs a specialized function. Your blood cells are very specialized. Blood is the only tissue made of cells that do not stick together. Other tissues like muscle, skeleton, and nerves are made of cells that join together to work together as a tissue. Blood cells, on the other hand, are designed to float separately throughout your body inside vessels called arteries and veins. Some blood cells can carry oxygen from your lungs to your tissues. Some are able to fight infection, while others can repair the arteries and veins they travel through. There are three main categories of blood cells: White blood cells, Red Blood Cells, and Platelets. Each has a particular job in your blood. When your blood cells arent doing their jobs correctly, it can make you sick. There are many different problems that can occur to make your blood cells perform poorly. A person who studies hematology can recognize what type of problem there is with the sick blood cells and why it is happening.

Hematology

A branch of medicine that deals with the morphology of blood and blood-forming tissues, and with their physiology and pathology. The science developed after Dutch microscopist, Anton van Leeuwenhoek observed red corpuscles in blood and compared their size with that grain of sand. This path breaking discovery set up a trend for further discoveries and the complete development of this science. The 18th century physiologist, William Hewson, improved the description of the red corpuscles, studied the lymphatic system, and demonstrated the role of fibrin in the clotting of blood. The recognition of bone marrow as the producer of red blood cells, new methods of staining cells and more information about the signs and symptoms of red blood cells, new methods of staining cells and more information about the signs and symptoms of pernicious anemia, leukemia and a number of other disorders of the blood acted as major breakthrough in the field of Hematology.

The 20th century opened with a new era in the science of Hematology. It saw great advances in this field. Form accurate blood transfusions to the study of anemia, and from the role of food on blood production to the use of liver extracts. Thus, the scope of hematology broadened further after the 2nd World War. Parallel discoveries in nutrition, biochemistry and all other fields of medicine saw hematology flourish as an independent branch of medicine.

Function of the Section

Confirm a physicians clinical impression of a possible hematological disorder Establish a diagnosis or rule out a diagnosis Detect and unsuspected disorder Monitor the effects of radiation or chemotherapy

List of tests
Routine Tests

A. Complete Blood Count (CBC)

The complete blood count (CBC), consists of while blood cell count, red blood cell count, hemoglobin, hematocrit, and white blood cell differential. Also included are the red blood cell indices, which indicate the relative and absolute hemoglobin content and size of the average red blood cell. When performing the differential, the while blood cells are identified and categorized, all cells are examined for abnormalities, and the platelets are reviewed for number and morphologic features. The importance of CBC count cannot be underestimated. It is a screening procedure that is helpful in the diagnosis of many diseases, it is one indicator of the bodys ability to fight disease, it is used to monitor the effects of drug and radiation therapy, and it may be employed as an indicator of the patients progress in certain diseases such as infections or anemia.

Physiologic Factors Affecting Test Results

Posture- Changing from a supine to a sitting or standing position results in a shift of body water from inside the blood vessels to the interstitial spaces. Larger molecules cannot filter into the tissues and concentrate in the blood. There will be significant increases in test values for lipids, enzymes and proteins. Diurnal Rhythm- Diurnal pertains to daylight, and diurnal rhythm refers to the daily body fluctuations that occur. Certain hormone levels such as cortisol and adenocorticotropic hormones, decrease in the afternoon. Other test values, such as iron and eosinophils, increase in the afternoon. Exercise- muscle activity elevates creatinine, protein, creatine kinase, aspartate transaminase, and lactate dehydrogenase values. Research also suggests that exercise activales coagulation and fibrnolysis and increase platelet counts. Stress- Anxiety can cause temporary increase in white blood cells as well as an acid-base imbalance. Dieting- Fasting means no food or beverages except water for 8-12 hours prior to blood draw. If a patient has recently eaten, there will be a temporary increase in glucose and lipid content in the blood. As a result, the serum or plasma may appear cloudy or turbid, which interferes with testing, especially with tests such as glucose, sodium, and complete blood counts. Smoking- Patients who smoke prior to blood collection may have increased WBC counts and cortisol levels. Long-term smoking can lead to decreased pulmonary function and result in increased hemoglobin levels.

Why is it done?

Find the cause of symptoms such as fatigue, weakness, fever, bruising, or weight loss. Find anemia. See how much blood has been lost if there is bleeding. Diagnose polycythemia. Find an infection. Diagnose diseases of the blood, such as leukemia. Check how the body is dealing with some types of drug or radiation treatment. Check how abnormal bleeding is affecting the blood cells and counts. Screen for high and low values before a surgery. See if there are too many or too few of certain types of cells. This may help find other conditions, such as too many eosinophils may mean an allergy or asthma is present. A complete blood count may be done as part of a regular physical examination. A blood count can give valuable information about the general state of your health.

Additives in Collection Tubes

ANTIGLYCOLYTIC AGENT This substance inhibits the use of glucose by blood cells. Such inhibition may be necessary if testing for glucose level is delayed. Examples of antiglycolytic agents are sodium fluoride and lithium iodoaceate. Tube containing sodium fluoride alone will yield serum. Potassium oxalate (an anticoagulant) is combined with sodium fluoride or potassium ethylene-diaminetetra-acetic acid (EDTA) to yield plasma for more rapid testing. ANTICOAGULANT This substance prevents blood from clotting. The mechanism by which clotting is prevented varies with the anticoagulant; for example, EDTA, citrate and oxalate bind with calcium, whereas heparin prevents the conversion of prothrombin to thrombin. Examples of anticoagulants are EDTA, sodium citrate, and lithium heparin. Tubes must be inverted several times to ensure proper mixing after collection, according to manufacturers instructions. CLOT ACTIVATOR This substance helps initiate or enhance the clotting mechanism. Clot activators include glass or silica particles that provide increased surface area for platelet activation and a clotting factor such as thrombin SEPARATOR GEL This inert material undergoes a temporary change in viscosity during the centrifugation process, enabling it to serve as a separation barrier between serum and cells or between plasma and cells. Because this gel may interfere with some testing, serum from these tubes cannot be used with certain instruments or for blood bank procedures.

WBC DIFFERENTIAL COUNT

The white blood cell differential count determines the number of each type of white blood cell, present in the blood. It can be expressed as a percentage (relative numbers of each type of WBC in relationship to the total WBC) or as an absolute value (percentage x total WBC). Of these, the absolute value is much more important than the relative value.

There are five basic white blood cell types: Neutrophils Eosinophils Basophils Lymphocytes Monocytes

WHITE BLOOD CELL COUNT

A white blood cell (WBC) count (sometimes called leukocyte count or white count) may be ordered by a physician as part of a complete blood cell count (CBC). A WBC count is the number of white blood cells per volume of blood, and is reported in either thousands in a microliter or millions in a liter of blood.

RED BLOOD CELL COUNT

The red blood cell (RBC) count is a blood test which determines the number of red blood cells, or erythrocytes, in a sample of blood. This test also evaluates the shape and the size of the red blood cells. All of this information is then used to determine the number of red blood cells per microliter of blood. Red blood cell count values vary according to the age and the sex of a patient. The RBC count ranges from 4.2-5.0 million red blood cells per microliter of blood for women and 4.6-6.0 million for men. A normal red blood cell count for children is typically between 3.8 and 5.5 million red blood cells per volume. This blood test is considered a very important indicator of a patients health. A low red blood cell count might mean the patient has anemia, acute or chronic blood loss, malnutrition, chronic inflammation, or a number of nutritional deficiencies including iron, copper, vitamin B-12, or vitamin B-6. On the other hand, a higher than average RBC count, called polycythemia, can be a sign of congenital heart disease, pulmonary fibrosis, or renal problems. An increase of red blood cells can also happen naturally, though. People who live at high altitudes tend to have a higher-than-average RBC count, and smokers generally have a higher number of red blood cells than non-smokers. An RBC count is almost always ordered as a part of the complete blood count (CBC), which determines the number of RBCs, white blood cells, and platelets. This blood test is also generally required for routine physicals and pre-surgical procedures. Patients with chronic anemia, hematological disorders, or chronic bleeding problems have their red blood cell count tested quite often so their physicians can keep track of any significant increase or decrease of red blood cells.

HEMATOCRIT (PACKED CELL VOLUME)

This test measures the amount of space (volume) red blood cells take up in the blood. The value is given as a percentage of red blood cells in a volume of blood. For example, a hematocrit of 38 means that 38% of the blood's volume is made of red blood cells. Hematocrit and hemoglobin values are the two major tests that show if anemia or polycythemia is present.

HEMOGLOBIN

The measurement of hemoglobin is one of several tests used to diagnose and follow the treatment of anemia. The normal range for the hemoglobin will vary with the age and sex of the individual. It should be noted that there may be some fluctuations in the hemoglobin being higher in the morning and lower in the evening. The hemoglobin may also show lower values when the patient is lying down, whereas strenuous muscular activity increase it. Smokers will have a tendency toward slightly higher hemoglobin levels. Altitude has the effect of raising the hemoglobin.

MEAN CORPUSCULAR VOLUME (MCV)

The MCV is a measure of the actual volume occupied by a red blood cell. This measurement is clinically significant in the presence of anemia as it allows for categorizing the type of anemia.

Causes of Macrocytic Anemia (Increased MCV) Poor diet Starvation Malabsorbtion Intestinal diseases Malignancy Hyperthyroidism Alcoholism Pregnancy
Causes of Normocytic Anemia (Normal MCV) Hemorrhage Hemolysis Bone marrow malfunction

MEAN CORPUSCULAR HEMOGLOBIN (MCH)

Mean corpuscular hemoglobin (MCH) is the average amount of hemoglobin per red blood cell in a blood sample. MCH is used to help diagnose the type (cause) and severity of anemia. When MCH is low, this can mean a person has iron-deficiency anemia. This type of anemia can be caused by insufficient iron in the diet or by blood loss. Blood loss, such as what might occur with tumors in the colon and other parts of gastrointestinal tract, can cause low iron levels and a low MCHC. High MCH levels may indicate the presence of macrocytic anemia and can have a variety of causes, including liver disease, and deficiencies of vitamin B12 and folic acid (folate). MCH is part of a Complete Blood Count (CBC) test.

MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION (MCHC)

The average hemoglobin concentration in erythrocytes (red blood cells). Mean corpuscular hemoglobin concentration (MCHC) is expressed in g/dl. Normal human values range from 32 to 36 g/dl. MCHC can be calculated as ([Hb]/Hct) 100 (i.e. the ratio of hemoglobin concentration to hematocrit times 100).

RED CELL DISTRIBUTION WIDTH

The red blood cell distribution width, or RDW, is a measure of the variation of red blood cell (RBC) width that is reported as part of a standard complete blood count. Usually red blood cells are a standard size of about 6-8m. Certain disorders, however, cause a significant variation in cell size. Higher RDW values indicate greater variation in size. Normal reference range in human red blood cells is 11 - 14%. If anemia is observed, RDW test results are often used together with mean corpuscular volume (MCV) results to figure out what the cause of the anemia might be. It is mainly used to differentiate an anemia of mixed causes from an anemia of a single cause. Vitamin B12 deficiency produces a macrocytic (large cell) anemia with a normal RDW. However, iron deficiency anemia initially presents with a varied size distribution of red blood cells, and as such shows an increased RDW. And in the case of a mixed iron and B12 deficiency we will have a mix of both large cells and small cells hence the RDW will usually be elevated. An elevated RDW, i.e. red blood cells of unequal sizes, is known as anisocytosis.

PLATELET COUNT

A platelet count is often ordered as a part of a complete blood count, which may be done at an annual physical examination. It is almost always ordered when a patient has unexplained bruises or takes what appears to be an unusually long time to stop bleeding from a small cut or wound.

MEAN PLATELET VOLUME

Mean platelet volume measures the average amount (volume) of platelets. Mean platelet volume is used along with platelet count to diagnose some diseases. If the platelet count is normal, the mean platelet volume can still be too high or too low.

B. Reticulocyte Count

A reticulocyte count is a blood test that measures how fast red blood cells called reticulocytes are made by the bone marrow and released into the blood. Reticulocytes are in the blood for about 2 days before developing into mature red blood cells. Normally, about 1% to 2% of the red blood cells in the blood are reticulocytes. The reticulocyte count rises when there is a lot of blood loss or in certain diseases in which red blood cells are destroyed prematurely, such as hemolytic anemia. Also, being at high altitudes may cause reticulocyte counts to rise, to help you adjust to the lower oxygen levels at high altitudes.

Why It Is Done A reticulocyte count is done to: See whether anemia is caused by fewer red blood cells being made or by a greater loss of red blood cells. Check to see if treatment for anemia is working. For example, a higher reticulocyte count means that iron replacement treatment or other treatment to reverse the anemia is working. What Affects the Test Reasons you may not be able to have the Figure 3-4: Site of reticulocyte formation test or why the results may not be helpful include: Taking medicines, such as levodopa, corticotropin, azathioprine (Imuran), chloramphenicol, dactinomycin (Cosmegen), medicines to reduce a fever, medicines to treat malaria, or methotrexate and other cancer chemotherapy medicines. Getting radiation therapy. Taking sulfonamide antibiotics (such as Bactrim or Septra). Being pregnant. Having a recent blood transfusion

C. Sickle Cell Test

A sickle cell test is a blood test done to screen for sickle cell trait or sickle cell disease. Sickle cell disease is an inherited blood disease that causes red blood cells to be deformed (sickleshaped). The red blood cells deform because they contain an abnormal type of hemoglobin, called hemoglobin S, instead of the normal hemoglobin, called hemoglobin A. Sickled blood cells are destroyed by the body faster than normal blood cells. This causes anemia. Also, sickled cells can get trapped in blood vessels and reduce or block blood flow. This can damage organs, muscles, and bones and may lead to lifethreatening conditions.

Erythrocyte Sedimentation Rate

The sedimentation rate (sed rate) blood test measures how quickly red blood cells (erythrocytes) settle in a test tube in one hour. The more red cells that fall to the bottom of the test tube in one hour, the higher the sed rate. When inflammation is present in the body, certain proteins cause red blood cells to stick together and fall more quickly than normal to the bottom of the tube. These proteins are produced by the liver and the immune system under many abnormal conditions, such as an infection, an autoimmune disease, or cancer. There are many possible causes of a high sedimentation rate. For this reason, a sed rate is done with other tests to confirm a diagnosis. After a diagnosis has been made, a sed rate can be done to help check on the disease or see how well treatment is working.

List of tests
Special Tests

Hams Test ( Acidified Serum Test)

The Ham test is done to diagnose paroxysmal nocturnal hemoglobinuria (PNH). The test checks whether red blood cells become more fragile when they are placed in mild acid. The red cells are tested for resistance to lysis during incubation with acidified fresh serum. Lowering of pH results in complement lysis of red cells with the PNH defect.

Sugar Water Test (Sucrose Hemolysis Test)

The sugar-water hemolysis test is a blood test to detect fragile red blood cells by testing their ability to withstand swelling in a low-salt solution.

Duke Bleeding Time

With the Duke method, the patient is pricked with a special needle or lancet, preferably on the earlobe or fingertip, after having been swabbed with alcohol. The prick is about 3-4 mm deep. The patient then wipes the blood every 30 seconds with a filter paper. The test ceases when bleeding ceases. The usual time is about 1-3 minutes.

Ivy Bleeding Time

The Ivy method is the traditional format for this test. While both the Ivy and the Duke method require the use of a sphygmomanometer, or blood pressure cuff, the Ivy method is more invasive than the Duke method, utilizing an incision on the ventral side of the forearm, whereas the Duke method involves puncture with a lancet or special needle. In the Ivy method, the blood pressure cuff is placed on the upper arm and inflated to 40 mmHg. A lancet or scalpel blade is used to make a shallow incision that is 1 millimeter deep on the underside of the forearm. A standard-sized incision is made around 10 mm long and 1 mm deep. The time from when the incision is made until all bleeding has stopped is measured and is called the bleeding time. Every 30 seconds, filter paper or a paper towel is used to draw off the blood. The test is finished when bleeding has stopped completely. A normal value is less than 9 and half minutes. A prolonged bleeding time may be a result from decreased number of thrombocytes or impaired blood vessels. However, it should also be noted that the depth of the puncture or incision may be the source of error.

Lee-White Clotting Time

The Lee-White-test is one of the global tests which allow the quantitative assessment of the coagulation system. It is used to determine the coagulation time: A shortened Lee-White test is meaningless. A prolonged test indicates a defect of the intrinsic system, or fibrinogen deficiency Absent coagulation is an indication for afibrinogenaemia

Prothrombin Time

Prothrombin time (PT) is a blood test that measures how long it takes blood to clot. A prothrombin time test can be used to check for bleeding problems. PT is also used to check whether medicine to prevent blood clots is working. A PT test may also be called an INR test. INR (international normalized ratio) stands for a way of standardizing the results of prothrombin time tests, no matter the testing method. So your doctor can understand results in the same way even when they come from different labs and different test methods. Using the INR system, treatment with blood-thinning medicine (anticoagulant therapy) will be the same. In some labs, only the INR is reported and the PT is not reported.

Why It Is Done Prothrombin time (PT) is measured to: Find a cause for abnormal bleeding or bruising. Check to see if blood-thinning medicine, such as warfarin (Coumadin), is working. If the test is done for this purpose, a PT may be done every day at first. When the correct dose of medicine is found, you will not need so many tests. Check for low levels of blood clotting factors. The lack of some clotting factors can cause bleeding disorders such as hemophilia, which is passed in families (inherited). Check for a low level of vitamin K. Vitamin K is needed to make prothrombin and other clotting factors. Check how well the liver is working. Prothrombin levels are checked along with other liver tests, such as aspartate aminotransferase and alanine aminotransferase. Check to see if the body is using up its clotting factors so quickly that the blood cannot clot and bleeding does not stop. This may mean the person has disseminated intravascular coagulation (DIC).

Activated Partial Thromboplastin Time

The activated partial thromboplastin time (APTT) test is used after you take blood-thinners to see if the right dose of medicine is being used. If the test is done for this purpose, an APTT may be done every few hours. When the correct dose of medicine is found, you will not need so many tests.

Partial Thromboplastin Time

Partial thromboplastin time (PTT) is a blood test that measures the time it takes your blood to clot. A PTT test can be used to check for bleeding problems. About 12 blood clotting factors are needed for blood to clot (coagulation). The partial thromboplastin time is an important test because the time it takes your blood to clot may be affected by: Blood-thinning medicine, such as heparin. Another test, the activated partial thromboplastin time (APTT) test, is a better test to find out if the right dose of heparin is being used. Low levels of blood clotting factors. A change in the activity of any of the clotting factors. The absence of any of the clotting factors. Other substances, called inhibitors, that affect the clotting factors. An increase in the use of the clotting factors.

PTT with Mixing Test

PTT is followed by mixing studies to check for possible coagulation factor deficiencies or inhibitors. The patients plasma is mixed with pooled normal plasma (a combination of blood from different donors that has normal amounts of all of the clotting factors). If the patient has a factor deficiency, mixing their plasma with pooled normal plasma should provide enough of the missing factor(s) for the PTT to correct (clot within the normal time frame). If it does correct, further coagulation factor testing is done to determine those factors that are deficient. If it does not correct, then the prolonged PTT may be due to a specific or nonspecific inhibitor. Further testing may then be done to check for antibodies to specific factors and to identify nonspecific antibodies, such as lupus anticoagulant and anticardiolipin antibodies.

Clot Retraction Time

The time required for a blood clot to separate from the tube wall and express serum, usually completed in 18 to 24 hours, but retarded or absent in persons with thrombocytopenic purpura.

D-Dimer

D-Dimer test is a blood test used to rule out active blood clot formation. If you have a negative (normal) d-Dimer result, that nearly rules out the possibility that you have a blood clot actively forming. If you have an elevated dDimer test reult, that does not mean that you have a blood clot; rather an elevated d-Dimer result means that additional testing may be needed to see if a blood clot exists.

Crystals in Synovial Fluid

Synovial fluid analysis may be ordered to help diagnose the cause of joint inflammation, pain, swelling, and fluid accumulation. Diseases and conditions affecting one or more joints and the synovial fluid can be divided into four main categories: Infectious diseases those caused by bacteria, fungi, or viruses. They may originate in the joint or spread there from other places in the body. These conditions include acute and chronic septic arthritis. Bleeding bleeding disorders and/or joint injury can lead to blood in the synovial fluid. Commonly present in patients with untreated blood clotting disorders such as hemophilia or von Willebrand Disease. Inflammatory diseases Conditions that cause crystal formation and accumulation such as gout (needlelike uric acid [monosodium urate] crystals) and pseudogout (calcium pyrophosphate dihydrate crystals). Typically affect the feet and legs. Conditions that cause joint inflammation, such as synovitis, or other immune responses. These may include autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus. Degenerative diseases such as osteoarthritis

Bone Marrow Test Bone marrow examination refers to the pathologic analysis of samples of bone

marrow obtained by bone marrow biopsy (often called a trephine biopsy) and bone marrow aspiration. A bone marrow biopsy may be done in a health care provider's office or in a hospital. Informed consent for the procedure is typically required. The patient is asked to lie on his or her abdomen (prone position) or on his/her side (lateral decubitus position). The skin is cleansed, and a local anesthetic such as lidocaine is injected to numb the area. Patients may also be pretreated with analgesics and/or anti-anxiety medications, although this is not a routine practice. Typically, the aspirate is performed first. An aspirate needle is inserted through the skin until it abuts the bone. Then, with a twisting motion, the needle is advanced through the bony cortex (the hard outer layer of the bone) and into the marrow cavity. Once the needle is in the marrow cavity, a syringe is attached and used to aspirate ("suck out") liquid bone marrow. A twisting motion is performed during the aspiration to avoid excess content of blood in the sample, which might be the case if an excessively large sample from one single point is taken. Subsequently, the biopsy is performed if indicated. A different, larger trephine needle is inserted and anchored in the bony cortex. The needle is then advanced with a twisting motion and rotated to obtain a solid piece of bone marrow. This piece is then removed along with the needle. The entire procedure, once preparation is complete, typically takes 10-15 minutes. If several samples are taken, the needle is removed between the samples to avoid blood coagulation.

Monospot Test (Heterophil Test)

This quick screening test detects a type of antibody (heterophil antibody) that forms during certain infections. A sample of blood is placed on a microscope slide and mixed with other substances. If heterophil antibodies are present, the blood clumps (agglutinates). This result usually indicates a mono infection. Monospot testing can usually detect antibodies 2 to 9 weeks after a person is infected. It generally is not used to diagnose mono that started more than 6 months earlier.

Euglobulin Lysis Time

The euglobulin lysis time (ELT) is a test that measures overall fibrinolysis. The test is performed by mixing citrated platelet-poor plasma with acid in a glass test tube. This acidification causes the precipitation of certain clotting factors in a complex called the euglobulin fraction.

Thrombin Time

Thrombin time compares a patient's rate of clot formation to that of a sample of normal pooled plasma. Thrombin is added to the samples of plasma. If the plasma does not clot immediately, a fibrinogen deficiency is present. If a patient is receiving heparin, a substance derived from snake venom called reptilase is used instead of thrombin. Reptilase has a similar action to thrombin but unlike thrombin it is not inhibited by heparin. The thrombin time is used to diagnose bleeding disorders and to assess the effectiveness of fibrinolytic therapy. Reference values for thrombin time are 10 to 15 seconds or within 5 seconds of the control. If reptilase is used, the reptilase time should be between 15 and 20 seconds. Thrombin time can be prolonged by: heparin, fibrin degradation products, lupus anticoagulant.

Flow of Specimen

Quality Assurance and Quality Control

Quality Assurance

Factors in Quality Assurance

To guarantee the highest quality patient care through laboratory testing, a variety of pre-analytical and post-analytical factors in addition to analytical data must be considered. Non-analytical factors that support quality testing include the following:

Qualified Personnel Established laboratory policies The laboratory procedure manual Proper procedures for specimen collection and storage Preventive maintenance of equipment Appropriate methodology Established quality assurance techniques Accuracy in reporting results

Qualified Personnel The entry-level examination competencies of all certified persons in hematology must be validated. Validation takes in form of both external certification and new employee orientation to the work environment. Continuing competency is equally important. Established Laboratory Policies Laboratory policies should be included in the laboratory reference manual that is available to all hospital personnel. The Laboratory Procedure Manual Laboratory procedures should be included in the manual.

Proper Procedures for Specimen Collection and Storage Strict adherence to correct procedures for specimen collection and storage is critical to the accuracy of any test. Pre-analytical errors are the most common source of laboratory error. The correct patient identification is critical. For hospital patients this is accomplished by checking the identification wrist band for the correct name and hospital identification number. For out-patients, the phlebotomist should ask for the full name and any other information specific for that patient. The correct specimen identification is equally important as patient identification. Each blood specimen obtained should be labeled with the patients first and last name, hospital identification number, patient location, time, date and the phlebotomists initials. Correct storage of specimens is critical to obtaining accurate results. Specimen integrity is an important issue when blood is collected at a site away from the testing facility. The sample tube should remain unopened before testing. Centrifugation and testing of such samples can be delayed for up to 2 hours at 22 to 24 C or for up to 4 hours at 2 to 4C. The sample must be kept in a well-chilled, properly insulated cooler or a refrigerated block. The storage device must have a thermometer to monitor its temperature to prevent overheating or partial freezing of the whole blood samples. Separation of the sample upon standing should not affect the sample integrity.

Preventive Maintenance of Equipment Continual monitoring of the temperature of water baths and refrigerators is important to the maintenance of reagent quality and test performance. Equipment such as microscopes, centrifuges, and spectrophotometers should be cleaned and checked for accuracy on a regular schedule. Failure to monitor equipment regularly can produce inaccurate test results and lead to expensive repairs.
Appropriate Methodology When new methods are introduced, it is important to check the procedure for accuracy and variability. Replicate analyses using control specimens are recommended to check for accuracy and to eliminate factors such as day-to-day variability, reagent variability and differences between technologists. Established Quality Assurance Techniques Each procedure should have and established protocol to assure the quality of the results. Usually, the normal and abnormal control samples are analyzed at the same time patient specimens are analyzed. Established limits of acceptable performance must be determined for each type of test. If control results are not within acceptable limits, patient results cannot be guaranteed to be accurate. In these cases, the source of error must be identified and the entire test repeated before a patients result can be reported. Accuracy in Reporting Results When extremely abnormal results or differences from previous test values are found, the laboratory protocol should establish the method of rechecking and reporting such results to the attending physician. Appropriate communication is critical to high-quality patient care. It is equally important in reporting results to be on alert for clerical errors, particularly transcription errors. The introduction of computer-interfaced, on-line reporting is useful in communicating information correctly and effectively.

Clinical Laboratory Safety

PRECAUTIONARY MEASURES: Universal precautions may be defined as a method for controlling infection which all blood and certain body fluids are treated as if infected with hepatitis B, human immune deficiency virus (HIV), or other disease- producing blood-borne pathogens. The reason for universal precautions is that all patients infected with blood-borne pathogens cannot be readily identified. Therefore, certain precaution techniques are used for all patients.

Handwashing is one of the most important safety practices. Hands must be washed with soap and water. If water is not readily available, antiseptic hand cleaners with paper towels can be used. The proper technique for Handwashing is as follows:

Wet hands and wrists thoroughly under running water Apple germicidal soap and rub hands vigorously for 10-15 seconds Rinse hands thoroughly under running water Dry hands with paper towel. Use the paper towel to turn off the faucet handles.

Hands must be washed: Whenever there is visible contamination with blood or body fluids After completion of work After gloves are removed and between glove changes Before and after eating and drinking, smoking, applying cosmetics of lip balm, changing contact lens, and using the lavatory Before and after all other activities that entail hand contact with mucous membranes, eyes, or breaks in the skin Eating, drinking, smoking, and applying cosmetics or lip balm must be prohibited in the laboratory work area. Food and drink must not be kept in the same refrigerator as laboratory Figure 5-3: Drinking inside a clinical laboratory is strictly prohibited. specimens or reagents or where potentially infectious materials are stored or tested. Mouth pipetting must be prohibited. Needles and other sharp objects contaminated with blood and other potentially infectious materials should not be manipulated in any way. Such manipulation includes resheathing, bending, clipping or removing the sharp object. Resheathing or recapping is permitted only when there are no other alternatives or when recapping is required by specific medical procedure. Contaminated sharps must be placed in a puncture- resistant container that is appropriately labeled with the universal biohazard symbol. The container must be leak-proof. Personal protective clothing and equipment must be provided to the worker.

Outer coveringsgowns, laboratory coats, sleeve protectors must be worn when there is a chance of splashing or spilling on work clothing. The outer covering must be made of fluidresistant material, must be long-sleeved, and must remain buttoned at all times. If contamination occurs, the protective clothing should be removed immediately and treated as infectious material. Gloves used for medical use are either sterile surgical or non-surgical examination gloves.

General guidelines related to the selection and general use of gloves include the following: Use sterile gloves for procedures involving contact with normally sterile areas of the body or during procedures for which sterility has been established and must be maintained. Use non-sterile examination gloves for procedures that do not require use of sterile gloves Wear gloves when processing blood specimens, reagents, or blood products. Gloves should be changed frequently and immediately if they become visibly contaminated with blood or certain body fluids or if physical damage occurs Do not wash or disinfect gloves for reuse. Washing with detergents may cause increased penetration of liquids through undetected holes in the gloves. Gloves must be use by phlebotomists, who have scratches, cuts or other breaks in the skin. The presence of skin lesions increases the likelihood of infection subsequent to skin exposure Gloves should be worn when the phlebotomist judges that hand contamination may occur Gloves should be changed between each patient contact. Eyewearfaces shields or goggles, and masks should be used when there is potential for aerosol mists, splashes or sprays to mucous membranes. Phlebotomy trays should be appropriately labeled to indicate potentially infectious materials. Specimens should be placed into a secondary container, such as a resealable biohazard labeled bag

HOUSEKEEPING AND WASTE MANAGEMENT: All work surfaces must be cleaned and sanitized at the beginning and end of the shift and whenever the bench area or floor becomes visibly contaminated. Disposable materials contaminated with blood must be placed in containers marked Biohazard and properly discarded. All blood spills are treated as potentially hazardous. In the event of a blood spill, the following procedure for cleaning up the spill is used Wear gloves and a laboratory coat Absorb the blood with disposable towels. Remove as much liquid blood or serums as possible before decontamination Using a diluted bleach solution, clean the spill site of all visible blood. Wipe down the spill site with paper towels soaked with diluted bleach Place all disposable materials used for decontamination into a biohazard container. Figure 5-3: The Biohazard Symbol Documentation of the disinfection of work areas and equipment after each shift is required. Infectious waste such as contaminated gauze squares and test tubes, must be discarded in proper biohazard containers. These containers should: Be conspicuously marked biohazard and bear the universal biohazard symbol Be of a universal colororange, orange and black, or red Be rigid, leak proof, and puncture-resistant

SAFETY MANUAL AND POLICIES

Each laboratory must have and up-to-date safety manual. This manual contains a comprehensive listing of approved policies, acceptable practices, and precautions including standard blood and body fluid precautions. Laboratories using radioactive test protocols must adhere to strict safety standards. Laboratory policies are included in a laboratory reference manual that is available to all hospital personnel. Such manuals contain information regarding patient preparation for laboratory tests.

Updates and Automation