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Criteria for Blood Smear Review

Article in Laboratory Medicine · May 2002

DOI: 10.1309/TVJW-ENEK-G1U3-WE0A

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 왗your lab focus 왘

CE Update [hematology | blood banking/transfusion medicine | cytology | histology | chemistry]

Criteria for Blood Smear Review

Gene L. Gulati, PhD, SH(ASCP)DLM, Mohammad Alomari, MD, William Kocher, MD, Roland Schwarting, MD
Jefferson Medical College and Thomas Jefferson University Hospital, Philadelphia, PA

After reading this article, the reader should be able to understand the who, what, where, when, and why of a blood smear review.
Hematology exam 0201 questions and answer forms are located after the “Your Lab Focus” section, p. 387.

왘 Blood smear review is defined as a ria specific for blood smears that must ual diffs are usually performed on
microscopic examination of an be reviewed.4 In this article, the au- specimens that are either flagged by
appropriately prepared and stained thors discuss the issue of blood smear the automated analyzer or reveal sig-
blood smear by a qualified review and provide a list of review nificant abnormalities in the CBC or
hematomorphologist. criteria which may be used as a guide automated diff results; whereas blood
왘 Blood smear review can serve as a by hematology laboratories. smear reviews are performed only on
quality control tool or as a means to cases selected mainly for clinically
assess competency of the technical What Is a Blood Smear significant findings in the CBC and/or
staff. Review? manual diff. A manual diff, which is
Blood smear review, for the pur- classified as a high complexity test by
Complete blood count (CBC) and pose of this article, is defined as a the federal government, may be per-
white cell differential (diff) are the 2 thorough and careful microscopic ex- formed by an associate degree holder
most frequently performed amination of an appropriately with an appropriate clinical laboratory
hematologic tests in the clinical labo- prepared and stained blood smear by a training; whereas the blood smear re-
ratories. Automated hematology ana- qualified hematomorphologist. After view, according to the CLA of the
lyzers, when appropriately calibrated, verifying the quality of the smear and CAP, must be performed by a hemato-
generate reliable results for both of stain, the reviewer will examine the morphologist.
these tests on many blood specimens. smear for clinically significant find-
The results of a significant proportion ings. All abnormalities should be What Purpose Does the Blood
of specimens are flagged by the ana- noted, suspected as well as Smear Review Serve?
lyzers, however, and require confirma- unsuspected, blood cells-related or Besides meeting accreditation re-
tion by other techniques. One of these otherwise. A complete examination quirement, review of blood smears by
techniques is the microscopic exami- should include observation under both a well-trained and experienced
nation of blood smear, generally low (x100) and high magnification hematomorphologist serves several
known as “manual diff.” The number (x500 and/or x1000). functions that are essential to patient
of manual diffs performed daily by The morphology of all cellular care. It serves as a quality
clinical hematology laboratories of elements is reviewed in addition to control/quality assurance (QC/QA)
many tertiary care medical centers is verification of the results obtained for tool for CBC, diff, and reticulocyte
quite large. Quality control of the the CBC and differential. The end count results. It can be used to assess
CBC and automated diff is made easy product is the confirmation or revision competency of the technical staff per-
and practical by the availability of of the CBC and diff results. Addition- forming manual diffs. Blood smear
commercial reference materials. In ally for new cases, a written report review allows appropriate interpreta-
contrast, for the manual diff, a com- should be generated by a laboratory tion of CBC and manual diff data with
mon means of quality control is the physician providing interpretation of other available laboratory findings and
review of selected blood smears by a hematologic and other available perti- clinical information. Such an interpre-
374 qualified individual.1-3 This type of nent laboratory and clinical findings. tation may provide a definite diagno-
review meets the accreditation Manual diff and blood smear review, sis or suggest a strategy for additional
requirement of the Commission on while similar to each other, do differ work-up of the case in an efficient and
Laboratory Accreditation (CLA) of the in certain aspects. cost-effective manner. Finally, it
College of American Pathologists A manual diff does not include serves as an excellent hematology
(CAP). The Commission on Labora- interpretation by a laboratory physi- teaching resource for training students
tory Accreditation of the CAP requires cian, whereas blood smear review and staff, and in the continuing educa-
each laboratory to have a list of crite- does, especially for new cases. Man- tion of technical staff.

laboratorymedicine> may 2002> number 5> volume 33 ©

 왗your lab focus 왘

Proposed criteria for blood smear review (for adults)

Criteria Initial Smears Follow-up Smears

T1
CBC
WBC (x 109/L or 103/µL) >30 yes no
HGB (g/dL) < 6 or >18 yes no
MCV (fL or cmm) < 75 or >105 yes no
MCHC (g/dL or %) > 36 yes no
PLT (x 109/L or 103/µL) < 50 or > 999 yes no

Differential
Lymphocyte # (x 109/L or 103/µL) > 4.0 yes no
Monocyte # (x 109/L or 103/µL) > 2.0 yes no
Eosinophil # (x 109/L or 103/µL) > 1.0 yes no
Basophil (%) >4 yes yes
Atypical lymph (%) > 10 yes yes
Blasts (%) any yes yes
Promyelocytes (%) >3 yes yes
Myelocytes (%) >5 yes yes
Metamyelocytes (%) > 10 yes yes
Other abnormal or unidentifyable cells any yes yes
NRBC (# per 100 WBC) >2 yes no
Organisms any yes yes

Significant morphological abnormality of RBC, WBC, and/or PLT* yes no

Blood Smear Review requested by clinician yes yes

*Significant morphologic abnormalities:

RBC (red blood cells):
Anisocytosis > 3+, Poikilocytosis > 3+, Hypochromia > 3+, Polychromasia > 3+
Basophilic stippling > 3+, Elliptocytes > 3+, Stomatocytes > 3+
Microcytes > 2+, Macrocytes > 2+, Target cells > 2+, Rouleaux > 2+
Tear drop cells > 1+, Schistocytes > 1+, Spherocytes > 1+, Acanthocytes > 1+
Sickle cells any, Howell jolly bodies any, Pappenheimer bodies any, agglutination any
WBC (white blood cells):
Dohle bodies > 3+, Hyposegmented neutrophils > 2+,
Hypersegmented neutrophils > 1+
Hypogranular granulocytes any, Auer rods any
PLT (platelets):
Giant platelets > 2+, platelet satellitosis > 1+

375
Who Should Specify the workable in its entirety for all laborato- upon their own knowledge, experience,
Criteria for Review? ries. It would have to be based solely on and judgment in developing the list of
A standard set of criteria developed the clinical significance of abnormal criteria most suited to the needs of the
by a professional organization such as CBC and diff findings and could serve patient population as well as to the con-
the CAP is perhaps what the clinical lab- only as a recommended guide. Until cerns of the clinicians, and to the level
oratories would like to have. Although such a set of criteria becomes available, of expertise of the technical staff at
feasible, such a set of criteria may not be laboratory professionals need to rely their institution.

© laboratorymedicine> may 2002> number 5> volume 33

 왗your lab focus 왘

Proposed manual diff delta values for selecting follow-up blood smears for review

Manual Diff Parameter Result Value (%) Delta Value (#)

T2
Neutrophils NA NA
Bands 30 20
Lymphocytes NA NA
Monocytes 20 20
Eosinophils 20 20
Basophils 10 10
4 4
Atypical Lymphocytes 20 15
10 10
Metamyelocytes 20 20
10 10
Myelocytes 20 10
5 5
Promyelocytes 10 10
3 4
Blasts 20 20
10 10
5 5
Plasma Cells 20 20
10 10
5 5
NRBC* (per 100 WBC) 100 50
75 25
50 20
25 15

*Nucleated red blood cells

Explanation for Delta Values Set-up in Laboratory Information System, using the example of NRBC in Table 2:
A delta value represents the degree of change from the latest previous result. The degree of change could be in absolute # or as a fraction in percentage. Furthermore the degree of
change could be set at different levels for different levels of results of any given test parameter. In the NRBC example in Table 2, the delta check function will look for a change in
absolute terms of 15 if the NRBC result is below 25 (0 to 24 per 100 WBC). In other words, if the current result for NRBC is 21 and the previous result for NRBC is 5, ie, a difference
of 16 (21 minus 5), a delta failure will occur and can be set to generate a reflex order for smear review. In the same example, if the result for NRBC is 25 or more but less than 50, the
delta check function will look for a change in absolute terms of 20. Since delta checks looks for a change irrespective of its direction (increase or decrease), some of the smears for
review will have normal diff results.

A laboratory physician, preferably a tors may vary among institutions, but blood smear, which may be missed even
hematopathologist, is the person most often include some or all of the follow- by skilled laboratory personnel, (x) ini-
suited to specify the criteria for blood ing: (i) the patient population served, tial vs follow-up blood smear(s), and
smear review. However, input from the (ii) concerns of clinicians, particularly (xi) teaching/educational considerations.
clinical staff and other qualified labora- those pertaining to specific patient pop-
tory professionals, such as a doctoral sci- ulations (eg, hematology/oncology pa- What Review Criteria Are
entist, supervisor, or senior tients), (iii) the training and experience Currently Used?
technologist(s) should also be utilized. of the laboratory physician(s), (iv) the A Medline literature search and
workload of the laboratory physician(s), review of the pertinent hematology and
376 What Factors Should Form the (v) the availability of the additional su- clinical pathology books revealed few
Basis for Review Criteria? pervisory staff, (vi) the training and ex- references that outline specific criteria
Clinical significance of the abnor- perience of the additional supervisory for blood smear review by pathologists
mal CBC and/or manual diff findings is staff, (vii) the training and experience of or other qualified laboratory profes-
the major determining factor in deciding the technical staff performing CBCs and sionals.
which blood smears need review. manual diffs, (viii) the workload of the The laboratory at the authors’
Nonetheless, several other factors often staff in the hematology laboratory, (ix) place of work currently uses 2 sets of
contribute to such a decision. These fac- the possibility of subtle changes in the criteria for blood smear review, 1 for

laboratorymedicine> may 2002> number 5> volume 33 ©

 왗your lab focus 왘

initial smears and the other for follow- <70 or >110) has been made to suit our encompassing work performed during
up smears. The interpretation of labo- patient population and our workload. all 3 shifts. To our knowledge, there is
ratory findings, though a major For newborn babies up to the age of 1 no rule indicating the number of smears
objective of the blood smear review, is week, the HGB, MCV, and NRBC cri- to be reviewed daily for the sole pur-
understandably most important on ini- teria are changed to <14 or >26; <90 or pose of QC/QA. However, based on our
tial smears. The follow-up smears of a >130; and >30 per 100 WBC, respec- experience with using the sets of crite-
given patient may require interpreta- tively. The lymphocyte criteria for chil- ria illustrated in T1 and T2, a 600 bed
tion, but only in case of significant dren up to the age of 6 is set at 8 x tertiary care center with a daily work-
change(s) in laboratory findings and/or 109/L. For reasons of availability and load of approximately 700 CBCs and
clinical condition. The set of review clinical significance, absolute numbers 185 manual diffs would review approxi-
criteria for initial smears is based on rather than relative percentages are uti- mately 8% (range of 5% to 10%) of
clinically significant findings of both lized for lymphocytes, monocytes, and blood smears daily. Initial and follow-
the CBC and differential. The review eosinophils. On the other hand, relative up smears with significant change(s)
criteria for follow-up smears, for the percentage rather than absolute number from previous results requiring inter-
purposes of QC/QA and competency of basophils was included because of an pretation by a laboratory physician rep-
evaluation, are based solely on clini- undesirable false positive rate for ba- resent approximately 3% (range of 2%
cally significant findings of the differ- sophils. For patient populations that to 5%) of all blood smears. The remain-
ential [T1]. Furthermore, the criteria come frequently to the hospital for care ing 5% represent an adequate number
for review of follow-up smears may be or check-up, such as those with chronic for QC/QA of manual diffs. Reviews
based on either the actual results [T1] disorders, blood smear review by a performed on initial or follow-up
or changes in results flagged by delta pathologist is performed only once per smears by qualified personnel can auto-
checks of selected manual diff parame- year unless a clinically significant matically serve the purpose of staff
ters [T2]. The selection of the change from the previous review is competency assessment provided ap-
proposed delta values outlined in T2 noted. propriate documentation is kept. Such
was guided by 3 factors, (a) clinical documentation should reveal that over a
significance of change in results of in- Who Should Perform the Blood period of time (usually 1 year) the com-
dividual parameters, (b) inherent im- Smear Review? petency of all personnel involved in
precision of manual diff results,5 and Blood smear review for the purpose performing manual diffs has been veri-
(c) authors’ personal experience with of quality assurance and competency fied and appropriate corrective action
the use of different delta values over assessment, while meeting accreditation has been taken, when necessary. The
time. Irrespective of the set of criteria requirement, may be performed by a use of smears selected for review, partic-
employed, good QC/QA practice re- laboratory professional qualified as a ularly the initial smears, for the training
quires that a few smears with normal hematomorphologist. Such a laboratory of pathology residents, hematopathology
manual diff results are also routinely professional could be a pathologist, su- fellows, medical students, medical tech-
reviewed in addition to the smears se- pervisor, or senior technologist, who, in nology students, and others, serves as a
lected for abnormal findings. Both sets the judgment of either the Laboratory useful teaching and continuing educa-
of criteria, as outlined in T1 and T2, Director or the Director of the Hema- tion resource.
meet this QC/QA requirement of re- tology Laboratory, has demonstrated
viewing a few smears with normal diff expertise in blood cell morphology and 1. Shively JA. Interpretive aspects of hematology
results. Based on the criteria in T1, it quality assurance. However, for the pur- tests with a focus on the blood film. In:
Hematology Laboratory Management and
is not uncommon to occasionally get pose of interpretation of laboratory Practice, Lewis SM, Koepke JA, eds. Oxford,
smears for review which have abnor- findings to help clinicians diagnose and England: Butterworth Heinemann Ltd; 1995:12-
mal CBC finding(s) but normal diff monitor their patients in an optimal and 19.
2. Payne BA, Pierre RV. Using the 3-part differential:
results. Similarly, the criteria in T2 cost-effective way, an appropriately Part I. Investigating the possibilities. Lab Med.
also regularly flag some smears for trained and/or experienced laboratory 1986;17(8):459-462.
review with normal diff results physician or doctoral scientist, prefer- 3. Bull BS. Quality assurance strategies. In:
because the delta-check failure can ably a hematopathologist, is desirable. Laboratory Hematology, Koepke JA, ed. New

occur with either an increase or

York, NY: Churchill Livingstone; 1984:999-1021.
377
4. Commission on Laboratory Accreditation,
decrease in results over the predefined How Often Should Smears be Laboratory Accreditation Program. Hematology
level. Both sets of criteria for follow- Reviewed for QC? and Coagulation Checklist for Hematology.
College of American Pathologists, Northfield, IL,
up smears have yielded an As a matter of good professional Edition 2001, question # HEM.34600.
approximately equal number of total practice and to meet requirements of 5. Rumke CL. The statistically expected variability
slides for review. Our laboratory is accrediting/regulatory agencies, the in differential leukocyte counting. In: Differential
Leukocyte Counting, Koepke JA, ed. Skokie, IL:
currently using the criteria outlined in QC/QA of manual diff should be per- Cap Conference/Aspen, College of American
T1 for adults. One modification (MCV formed daily on a fraction of smears Pathologists; 1977:39-45.

© laboratorymedicine> may 2002> number 5> volume 33

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