Vol. 14 •Issue 25 • Page 14
Advances in Hematology Testing
No matter what their size, all hematology laboratories face the same challenge: how to deliver accurate patient test results as quickly as possible. As workload grows and staff size dwindles, the pressure to lower costs becomes more intense–but laboratorians should take heart. In an effort to help us meet these challenges, diagnostic instrument manufacturers now offer advanced instrument systems with automation and expanded testing capabilities to decrease turnaround time and deliver quantifiable productivity results.
At St. Joseph Medical Center, Towson, MD, our clinical laboratory is always looking for ways to improve processes and deliver faster, more accurate results to medical staff. Recently, this meant taking a second look at our hematology department, which was in need of streamlining and modernization.
We decided to replace our flow cytometer and aging hematology analyzers with two high-throughput COULTER® LH 750 hematology systems (Beckman Coulter Inc., Fullerton, CA). In doing so, we automated sample processing, decreased slide review using decision rules and transferred reticulocyte counting from a stand-alone flow cytometer to the hematology systems. The benefits we’ve experienced demonstrate how today’s more advanced hematology analyzers offer features too compelling to ignore.
Planning for More Work
Though we expected many benefits, there was one major reason we introduced new technology in the laboratory: We expected a significant increase in work. St. Joseph Medical Center, an affiliate of Catholic Health Initiatives, provides one of the largest open-heart surgery and cardiac catheterization programs in the state of Maryland. The medical center is currently very busy and work is only expected to increase. In fact, the emergency department alone predicts a workload increase of 40 percent over the next five years.
Even without the expected work increase, the core laboratory shoulders a heavy workload, analyzing roughly 100,000 hematology samples annually. Of these, 40,000 blood cell profiles require no differentials, and 70,000 require complete blood counts (CBCs) with differentials. In addition, the lab performs 5,000 reticulocyte counts annually.
We knew that in order to manage a growing number of tests, we would need to take full advantage of the technology features available on new hematology analyzers.
Sample Processing
In the hematology laboratory, there are many labor-intensive tasks that comprise the testing cycle. For clinical laboratories, this spells opportunity, since many hematology instruments offer a number of ways to automate sample processing.
The preanalytical phase, for example, can be improved by using hematology instruments that offer true random access by profile type, including CBC, CBC with differentials, CBC with differentials and reticulocytes, CBC with reticulocytes or reticulocytes only. This saves laboratorians from having to presort samples; they can place tubes in any position and the instrument will run the test that is ordered for each specific sample.
In the postanalytical area, process improvements can be gained by automating the slide preparation process. For example, an option available on some hematology systems is the ability to automate slide making and slide staining. In this scenario, the laboratorian can program the analyzer to make a smear with a single aspiration of the sample if the results fall within a certain range. The automated process creates a wedge smear that offers a large microscopic viewing area and meets all NCCLS standards. The slide is prepared automatically, which reduces turnaround time and saves labor costs.
Automated slide making and slide staining can work hand-in-hand. Using the manufacturer’s recommended staining protocols or by modifying those protocols, labs can obtain the desired stain, color and quality that best fits their needs. Slides made offline can be added to the automated slidestainer.
Additional process improvements can be achieved by automating the patient result review process, which can directly impact turnaround time and increase efficiency in laboratories. At St. Joseph Medical Center, using decision rules, we have seen a marked decrease in the number of samples that require manual review. In fact, 40 percent of the samples automatically pass through the analyzer without slide review, compared to 22 percent on our previous hematology analyzer. This reduced our slide review rate by 1,125 hours—a significant timesavings.
Not only do decision rules assist in decreasing slide review, but they also can assist in consistent follow-up when a sample needs to be reviewed. Indeed, when it comes to post-analytical decision support, decision rules are a powerful tool for any hematology lab, allowing laboratorians to improve productivity and deliver faster patient test results to clinicians. For example, decision rules provide important criteria that can be used to automatically validate test results. Often referred to as autovalidation or autoverification, this method allows analyzers to validate and release normal test results, while flagging abnormal specimens for manual review by technologists.
Automated Reticulocyte Counting
Manual–or eye count–reticulocyte counting has been standard in many laboratories for years; however, the method runs the risk of large sampling errors, because the proportion of reticulocytes in normal individuals is so small. By automating the counting process, labs can save not only time, but also increase test result reliability and eliminate errors.
In the past, some labs have opted to perform reticulocytes on flow cytometers to improve accuracy and precision of the counts. We found that we could be more efficient by transferring the method from our flow cytometer to our new hematology systems. Because reliability is a critical issue, we wanted to verify reticulocyte count performance using our new hematology analyzers compared with counts using flow cytometry. When we compared results, we discovered that reticulocyte correlations for the new systems were excellent over a wide range of clinically important values.
In addition to improving reliability, automated reticulocyte counting can help a laboratory consolidate workflow, since laboratorians who used to manually count reticulocytes can now focus on other important activities, such as reviewing abnormal results. Meanwhile, the lab is able to deliver comprehensive, reliable results quickly.
More Information, Less Time
Today’s hematology labs are also in need of instruments that feature expanded differential analysis and improved linearity of hemoglobin, white blood cell counts and platelets. Our new systems offer a six-part differential, with the sixth parameter being nucleated red blood cells (NRBCs). Improvements in identifying and counting these cells can help physicians diagnose and monitor sickle cell disease, beta thalassemia major, neonates and malignancies involving bone marrow. This data is especially important because our laboratory serves neonatal intensive care, critical care and oncology patients.
Manually counting NRBCs is labor intensive and, like reticulocyte counting, can be imprecise. But by drawing on today’s automated technology, laboratories can complete enumeration accurately and quickly.
Lessons Learned
By modernizing and streamlining our laboratory, we have achieved quantifiable timesavings and productivity improvements—with more to come. Many of our laborious manual processes have been replaced with fast, accurate automated technology, which has contributed to lower costs. This convenience allows technologists to concentrate their expertise on activities that require critical analysis, and it helps the laboratory redirect its resources to manage an ever-expanding workload.
But today’s hematology technology is only paving the way for new, more innovative advancements. For example, we are investigating automation technology that will allow us to become one of the few clinical laboratories in the country to automate the entire hematology testing process, including sample loading, unloading, tracking for reflex or repeat testing, and sorting for tests such as sedimentation rates, hemoglobin electrophoresis and HbA1c. By automating this process, we will further improve our turnaround time and testing accuracy, as well as free up technologists to concentrate on other tasks.
The lesson for other laboratories? Take advantage of today’s more advanced hematology instruments. The technology will help you become a more efficient laboratory that can deliver accurate results quickly and cost-effectively.
Anthony D. La Porta is the laboratory manager and technical director at St. Joseph Medical Center, Towson, MD.
