SYSMEX EDUCATIONAL ENHANCEMENT
AND DEVELOPMENT | MARCH 2017
SEED HAEMATOLOGY
Quality control materials: the better you treat them,
the more you can trust your haematology results
One vital part of quality assurance is the internal quality IQC is conducted by running one or more control materials
control (IQC), which is used to ensure day-to-day consis- on the analysis system that is to be checked. The control
tency of an analytical process, helping to determine whether materials undergo an analytical procedure identical to that
patient results are reliable enough to be released. Perform- applied to patient samples. The results are plotted on con-
ing IQC also enables the laboratory to monitor and docu- trol charts as described by Levey-Jennings, and those charts
ment the quality of its work. In most of the countries it is are interpreted in the usual fashion.
required to perform IQC by national regulations.
Sounds simple? Well, it’s not entirely simple. There are
There are four main purposes of IQC: factors that need careful consideration if the IQC system is
1. To monitor the complete analytical process. to represent a lab’s routine analytical operation adequately.
2. To detect immediate errors that occur due to
a) a failure of the analytical system, Requirements QC materials have to meet
b) adverse environmental conditions, or Controls are materials that contain an established amount
c) operator performance; for example maintenance of the substance to be tested – the analyte. Controls have to
procedures being carried out differently because of be tested at the same time and in the same way as patient
a change of operator, etc. samples. The purpose of the control is to validate the reli
3. To monitor the long-term test performance that may ability of the analysis system and to evaluate operator per-
be influenced by changes in the performance of the formance and environmental conditions that might have
a) analytical system, an impact on the results. It is particularly critical to select
b) environmental conditions and appropriate control materials.
c) inter-operator variance.
4. To provide proof of an adequate long-term quality The best materials for IQC are typical samples of the routine
level and to comply with regulatory requirements. test materials, assuming that they are sufficiently stable for
the purpose. Table 1 lists recommended properties of quality
SEED Haematology – Quality control materials 2
Sysmex Educational Enhancement and Development | March 2017
control materials as per recommendations of the Hong Kong Sysmex control materials are ready to use. All controls are
Association of Medical Laboratories (HKAML) [1]. Addition- delivered in vials with sufficient material for the control
ally, it has to be taken into consideration that control ma period and are measured with the same measuring principle
terials need to be different from calibrator materials [2]. as patient samples.
Table 1 Recommended properties of a QC material For all diagnostic whole blood parameters Sysmex delivers
controls in the low, normal and high analytical range and
1. It should resemble a human sample (blood, plasma,
serum, CSF, etc.). in order to check body fluid parameters, we provide two
2. The analyte concentration should be at medically control levels.
significant levels. It should span the clinically important
range of an analyte’s concentration.
For the manufacturing of our haematology control materials,
3. The material matrix should be as much like the human
sample as possible. we trust the well-known producer Streck, Inc. (Nebraska,
4. Constituents should be stable for a long period USA), who is recognised worldwide as the leader in cell
of time. stabilisation. Streck’s core competence is the development
5. After the vial has been opened and material prepared it of quality control materials that are tailored to the custom-
should be stable during the period of use.
ers’ needs.
6. The control material should be ready to use and require
minimum preparation.
7. Convenient sizes of aliquots/vials can be prepared and Transportation, storage conditions and shelf life
vial-to-vial variability should be low. Sysmex haematology control materials are to be stored
8. It should be reasonably priced (optional). with a closed cap at 2 – 8°C. A short-term increase in tem-
9. The control material should be tested in the same manner perature, which may occur during transportation, does not
as patient specimens.
affect the quality of the product. All haematology control
materials must be protected from freezing. When handled
QC materials from Sysmex in this manner, the products are guaranteed stable until the
Manufacturing quality control materials for haematology is expiration date stated on the package and vials. Once the
a challenge compared with controls for clinical chemistry if vials have been opened or sampled by cap piercing, they will
all the points mentioned above shall be covered. Native cells retain stability – depending on the product type – as stated
naturally have a very limited survival rate. To extend a cell’s in Table 2.
life to a longer period, efficient stabilisation is needed. Due
to this, haematology quality control material is different to Table 2 Stability of Sysmex haematology controls
freshly collected patient samples. This means care must be
Control material Period of use Open vial stability
taken to ensure the material has been used correctly when
Eightcheck-3WP 84 days 7 days
interpreting quality control results.
e-Check (XS) 56 days 14 days
Sysmex control materials include stabilised human red blood e-Check (XE) 56 days 7 days
cells (RBC), white blood cells (WBC), and a platelet (PLT) and XN-L Check 84 days 15 days
nucleated red blood cell (NRBC) component in a preserva- XN Check 56 days 7 days
tive medium. They are free from any artificial components
XN Check BF 56 days 30 days
that simulate cells, such as latex particles. However, a micro-
scopic white blood cell differential cannot be accomplished
with this material, as the white blood cells have been treated Preparation of XN-Class QC materials before
to enhance their stability. This means they will not stain to measurement
demonstrate the typical cell morphology known from May- When storing and preparing quality control materials it is
Gruenwald-Giemsa staining. But regarding lysing and stain- important to carefully adhere to the manufacturer’s instruc-
ing behaviour with the analyser reagents, the stabilised cells tions for storage and equilibrating.
only show small differences to fresh blood cells. These dif-
ferences are the reason why the analyser uses a QC mode
to produce and display the measurement results.
SEED Haematology – Quality control materials 3
Sysmex Educational Enhancement and Development | March 2017
1. Remove the vial from the refrigerator and equilibrate You can also watch a movie about the mixing of the quality
with room temperature (15 – 30°C) for at least 15 minutes control vials on our webpage:
before use. http://www.sysmex-europe.com/media-center/sysmex-
2. Roll each vial between the palms of your hands for 15 qc-material-preparation-26847.html
seconds (see Fig. 1).
3. Holding the vial from end to end between the thumb A simple procedure with a great impact
and forefinger, invert the vial 20 times using a very quick When the result of a QC measurement falls outside its limits,
turning motion of your wrist during mixing. Details can analysis should be stopped, patient results held, and the
be seen in a video on the CD-ROM or USB stick accom analysis system investigated. As soon as error sources have
panying each QC lot (see Fig. 2). been identified and corrections made, the measurement
4. Analyse the QC material on the instrument according of control material should be repeated. If the results read
to the Instructions for Use. The pierceable septum in the correctly, then patient samples (those from the period of the
vial cap allows sampler analysis. last correct QC measurement until the QC error has been
5. Subsequent analyses during this test period may be discovered and solved), along with another quality control
performed by inverting the vial 5 times prior to instru- specimen, should be repeated. Do not simply repeat the
ment analysis. testing without looking for sources of error and taking cor-
6. Return the vial to the refrigerator (2 – 8°C) for storage. rective action.
According to the World Health Organisation (WHO),
possible problems to consider include [3]:
■■ Degradation of reagents or kits
■■ Control material degradation
■■ Operator error
■■ Failure to follow manufacturer’s instructions
■■ An outdated procedure manual
■■ Equipment failure
Fig. 1 Roll the QC vial for 15 seconds between the palms of your hands. ■■ Calibration error
In haematology it can be generally observed that a lot
of problematic QC results derive from incorrect handling
or inappropriate storage of the material. Also using out-
dated materials or vials with too little remaining volume
leads to erroneous results. Especially haematology controls
deserve accurate treatment before measurement as they
contain blood cells that need to be homogenized before
measurement.
Below, some examples are shown where the results have
been out of their range due to mistreatment of the QC
material. Changes in the numerical results, particularly of
the complete blood count (CBC) and reticulocyte parame-
ters, can be observed. Checking the cell distributions in his-
tograms and scattergrams can also help to reveal differences
Fig. 2 Invert the vial 20 times holding it from end to end, using a to results obtained from correctly treated material. Measure-
very quick turning motion of your wrist during mixing.
ment examples and scattergram images of all control levels
can be found on the CD-ROM or USB stick that always ac-
companies the QC material for comparison purposes.
SEED Haematology – Quality control materials 4
Sysmex Educational Enhancement and Development | March 2017
Incorrect mixing and its effects
Platelets
Identifying mixing problems is generally difficult as it de-
121
pends on both the intensity and duration of mixing. How-
ever, taking a closer look at the two extremes (insufficient
87
vs. overmixing) reveals that numerical results of WBC, RBC
and PLT can be distorted due to the use of an incorrect mix-
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An overmixed sample is generally more difficult to identify
and occurs more rarely. If the sample is mixed for too long a Fig. 3 Experiment results using XN Check Level 1 with two different
mixing procedures
time with high speed, slightly elevated WBC counts together
with markedly increased PLT counts can be observed. Never
mix the haematology QC vials on an automated roller or Table 4 Quantitative analysis of the experiment’s results
mixing device! Phase 1 Phase 2 Phase 3
(correct (insufficient (correct
mixing) mixing) mixing)
In contrast to that, samples that are not mixed sufficiently
Assay mean
can be identified by markedly increased RBC counts and 87 87 87
for platelets
related parameters (HGB, HCT) and decreased WBC counts Mean 87.0 80.2 86.3
and low counts of PLT-I especially in Level 1 with increased
Deviation (%)
0.0 – 7.8 – 0.8
coefficient of variation (CV) values. Table 3 compares the from assay mean
results of improperly mixed QC samples. Standard
2.8 4.7 2.4
deviation (SD)
Table 3 Results of improperly mixed QC samples CV (%) 3.3 5.9 2.8
Not mixed Overmixed
WBC WBC ()
The effect of incorrect temperatures on quality
RBC, HGB, HCT not markedly
RBC, HGB, HCT control material
influenced
Not only mixing but also temperature has an influence on
PLT-I (Level 1) PLT-I
the results obtained from quality control materials. Haema-
Aspirated from the sediment, Red blood cells are destroyed
more red blood cells are and fall by size into the tology controls must be stored refrigerated, but may only
measured, but white cells are PLT area, where they are then be used after equilibration with room temperature for at
underrepresented or missing. counted as platelets.
least 15 minutes. Storing QC materials below 2°C, even short-
term, has an immediate impact on the cells and results in
Applying an incorrect mixing procedure leads to increased haemolysis, as shown in Table 5.
CV values for most parameters as shown in Fig. 3 and Table
4. This was done as an experiment to demonstrate the influ- A haemolysed QC material can be recognised by a colour
ence of the mixing procedure on platelet results. Two differ- change from red to brownish black inside the vial, as shown
ent mixing procedures were used. For the measurements of in Fig. 4.
phase 1 and 3 ( ) the correct mixing procedure was applied,
whereas in phase 2 ( ) the QC material was less inten-
sively mixed than described in the package insert. Platelet
results were more imprecise and significantly lower than the
assay mean value.
SEED Haematology – Quality control materials 5
Sysmex Educational Enhancement and Development | March 2017
Table 5 Results of QC samples stored at incorrect temperatures
Frozen Overheated
RBC , HGB ,
MCV , MCV (),
MCH , MCH
RDW-SD ,
RDW-CV
PDW, MPV (), PLT
P-LCR (),
PCT
Abnormal platelet No abnormal platelet
distribution visible distribution visible
RET , RET
RET-He ,
RBC-He
The membranes of the red blood cells are damaged during freezing, Due to overheating the proteins in the sample are denatured
which results in haemolysis and therefore in lower counts plus and are recognised by the analyser as small particles, getting
disturbance of the red cell parameters. Although the PLT histogram included in the measurement of platelets. Plus the turbidity of
is clearly disturbed by larger particles resulting from burst RBC, the sample increases, which also disturbs the photometric meas-
the PLT count may still lie within the assay range. HGB remains urement of HGB.
stable since for the haemoglobin measurement the red blood cells
need to be lysed anyway. Reticulocyte measurement is totally The increased debris can also be observed in the reticulocyte
disturbed and RET-He and RBC-He results are far too low. scattergram. The entire population shifts down.
Fig. 4 Comparison of a non-haemolysed QC sample (left) with a
haemolysed QC sample (right)
SEED Haematology – Quality control materials 6
Sysmex Educational Enhancement and Development | March 2017
Conclusion – why should one bother References
Small things can have a great impact. So has the mixing [1] Phang R et al. (2009): A Practical Guide to Internal Quality
Control (IQC) for Quantitative Tests in Medical Laboratories.
procedure of QC materials in haematology! As could be
Proposed Guidelines.
seen above, it greatly influences the QC measurement
[2] CLSI C24 – A3 (2006): Statistical Quality Control for Quantitative
results. Damages that occur to the vial neither reflect a
Measurements: Principles and definitions – Approved Guideline.
defect of the analyser nor the necessity for calibration.
[3] WHO Content Sheet 7 – 1: Overview of Quality Control for
Therefore, it is of utmost importance to store and treat
Quantitative Tests.
the quality control materials in the way the manufacturer http://www.who.int/ihr/training/laboratory_quality/7_b_content_
quant_qc.pdf
describes.
The main objective of a laboratory is to provide reliable,
timely and accurate test results to the requesting persons.
To continuously achieve this day in, day out, you need
consistent monitoring and evaluation of the laboratory’s
performance, and – in case of non-conformance to the pro-
cedures – the implementation and follow-up of corrective
actions. A poor approach can lead to the validation of in
correct patient results, potentially setting off a spectrum of
undesirable scenarios and legal actions in the worst case
scenario.
Design and specifications may be subject to change due to further product development.
Changes are confirmed by their appearance on a newer document and verification according to its date of issue. © Copyright 2017 – Sysmex Europe GmbH
Sysmex Europe GmbH
EN.N.04/17
Bornbarch 1, 22848 Norderstedt, Germany · Phone +49 40 52726-0 · Fax +49 40 52726-100 · [email protected] · www.sysmex-europe.com
You will find your local Sysmex representative’s address under www.sysmex-europe.com/contacts
