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Principle: | Specimen: | Materials: | Reagents: | Procedure: | Critical Values/Action | Suspect Messages | Instrument Flags: | Differential Review: | Competency: | Quality Control:

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Peripheral Blood Smear (PBS) Review, Technologist/Pathologist

Appendix A

Appendix B

Competency

Critical Values/Action Levels

Differential Review

General Review Criteria

Instrument Flags

Materials

Platelet Estimate

Quality Control

Specimen

Suspect Messages

WBC Estimate

I. Principle:

The blood smear examination provides a visual confirmation of automated instrument results, and in some instances, may provide morphologic clues for a specific case finding. A properly made peripheral smear is examined to identify RBC, WBC, and PLT morphology, estimate hematologic counts, perform WBC differentials and confirm the accuracy of automated differentials.

II. Specimen:

A Wright’s stained peripheral smear made from whole blood collected in EDTA anticoagulant. Refer to the “Peripheral Blood Smear Preparation: Miniprep”, “Wright Stain Manual; PBS and Bone Marrow” and “Hema-Tek Slide Stainer, Operate” procedures for preparation of Wright Stained smear.

Note: Ensure that the entire feathered edge is appropriately stained since that is the area of the slide being examined.

Refer to the QA Manual “Specimen Integrity; Hematology” for specimen requirements.

III. Materials:

  1. Microscope:
    1. The microscope should have appropriate blue or neutral density filters, which will enable clear-cut differentiation between the blue and red shades of Wrights Stain. The intensity of the lamp must be adequate for viewing through oil immersion lenses. The condenser should be properly focused, and field and condenser iris diaphragm set for maximum resolution with oil immersion objective.
    2. Our defacto standard for microscope field # is based on a field size defined by a fixed ocular diaphragm of 18 mm diameter. In order to obviate the need for scope-specific procedures, the scopes with larger field of view have been corrected to the standard by means of a custom reticle that has been installed in the right-side oculars. The reticle superimposes a thin circle over the visible field. When counting formed elements, count only those target elements, which fall within the circle.
  2. Differential Cell Counter

III. Reagents:

Immersion Oil (Cardinal Health #M6005-4H)

IV. Procedure:

General Criteria for Review

  1. The following criteria or flags from the Beckman/Coulter LH 750 & LH 500, automated hematology instrumentation, may trigger peripheral blood smear (PBS) review:
    1. Critical Values/Action Levels
    2. Suspect Messages
    3. Instrument Flags
  2. Neonates (Infants <30 days old) – These patient samples always require tech review and a manual differential. They require pathologist review only if a slide shows abnormal cells, abnormal cell morphology, or NRBCs. Refer to Appendix A and Appendix B for other criteria.
  3. Veterinary specimens – These samples always require a manual differential. Review for RBC morphology and for the presence of inclusion bodies. No other RBC flags are reported. A pathologist review is not necessary.
  4. For review criteria regarding Medical Associates Oncology patients, refer to Appendix C.

Recording Results

  1. When a manual PBS is performed:
    1. Record all results on the LH printout.
    2. Enter results on the Manual PBS screen in CLICS.
    3. Legibly sign and retain the printed LH report as the primary record and attach it to the patient requisition.
  2. Pathologist Review
    1. The following items are needed for a pathologist’s review:
      1. Patient requisition
      2. Peripheral blood smear
      3. Instrument printout, including technologist’s comments and initials
      4. Most recent cytogram from Web Inquiry, if applicable
      5. Enter the Canned Comment “Subject to pathology review” in the Report Comment field of CLICS.
    2. Enter all other comments, such as why the slide is being reviewed and what is seen, in Lab Comments with “Reviewed by (your initials).” Remember to enter lab comments between *asterisks*.
    3. Make sure at least one parameter (such as the MPV) is put on hold so the patient stays on the Instrument Review screen. This allows the pathologist to enter their comments before the entire report is released.
    4. The pathologist will enter their review comments into Reported Comments followed by “Reviewed by (pathologist initials)” and then release the patient report.

Slide Examination

  1. Low Power (10X):
    1. Examine for adequate staining, and evaluate the slide for an even distribution of leukocytes, erythrocytes, and platelets. Find a usable area representative of the various cell types that will be counted. Scan for immature cells, infrequent cell types, NRBC’s, platelet clumps, and Rouleaux, while assessing cellular distribution.
    2. Perform a WBC Estimate.
      1. Count the number of WBCs on low power where the red cells form a uniform monolayer. Divide the number by 4 to obtain the number of WBC/LPF. Then multiply the number by 1,000 to obtain the estimated total WBC count.
      2. If there is a marked discrepancy between the estimate and the automated WBC count, recheck the smear for abnormal distribution of cells. If this does not explain the discrepancy, repeat the WBC, make a new smear, and check for possible slide/specimen/report mix up.
  2. Oil Immersion (100X):
    1. Perform a Platelet Estimate.
      1. Scan the smear around the edges on high power to make sure there are no platelet clumps, giant platelets, platelet satellitism, microcytic erythrocytes, and/or small red cell fragments. (If platelet clumps are seen, refer to section VI.1.)
      2. View the slide under oil immersion where the red cells form a uniform monolayer. Count the number of platelets in 10 fields and then calculate the average number per field.
      3. Take the average number of platelets/OIF and multiply by 18,000 to obtain the estimated total platelet count. If the manual platelet count agrees with ± 25% of the automated count, the automated count will be reported. If they do not agree, consult a pathologist.
        Note: Record the WBC and Plt estimates on the LH printout.
    2. RBC Morphology Examination. Review a minimum of 10 oil immersion fields (OIF) when determining how many abnormal cells to call per field. For grading criteria and when to leave for Path review, refer to Appendix A.
    3. Perform a manual white blood cell differential if the review criteria are met.

V. Critical Values/Action Levels:

See the Critical Value Chart for all critical values. Critical Values that are low will be flagged as “cL”. Critical Values that are high will be flagged as “cH”.

Since demographics are not uploaded to the LH instruments, the instrument will flag Adult Critical Values only.

Note: Results on infants and children with critical values will not flag on the LH, but they will flag in CLICS. Refer to the Critical Value Chart for values.

Action Levels:

  1. White Blood Cells (WBC)
    Action: <3.0 or >30 (x103 cells/µl)

    Note: If the WBC is <0.5 x 103/µl and a manual differential is required, the “LUC-diff” must be entered as 100. The other differential parameters are entered as 0 (zero). Enter the Canned Comment “WBC too few to differentiate” in the Report Comment field of CLICS. This does not require pathologist review providing all other review criteria have been met.
    1. Release result from the LH to CLICS
    2. Check Web Inquiry to see if the patient was reviewed within 90 days.
      1. Has been previously reviewed, release the result and document in Lab Comments when it was last reviewed and by whom.
      2. Has been previously reviewed, but fails the check, tech review for any abnormal or immature cells. Refer to Appendix B for WBC review criteria and when to leave for pathologist review.
      3. Has not been reviewed, perform a tech review for any abnormal or immature cells. Leave for pathologist review first time only.
    3. Other WBC Review Criteria:
      1. LH gives no differential or an incomplete differential – perform a manual differential. Refer to Appendix B for WBC review criteria and when to leave for Pathologist review.
      2. Absolute (#) values for the WBC parameters:
        Neutrophils #: <1.0 or >20.0
        Lymphocytes #: >5.0 (>12yrs); >7.0 (≤ 12yrs)
        Monocytes #: >1.5 (>12yrs); >3.0 (≤ 12yrs)
        Eosinophils #: >2.0
        Basophils #: >0.5
        1. Check Web Inquiry to see if the patient was reviewed within 90 days.
        2. Has been previously reviewed, release the result and document in Lab Comments when it was last reviewed and by whom.
        3. Has not been reviewed, perform a tech review for any abnormal or immature cells. Hold the differential and leave for pathologist review first time only.
      3. Eosinophils or Basophil ≥ 20% (This will flag in CLICS as an “unlikely” result.)
        1. Check Web Inquiry to see if the patient had a similar result in the past 90 days and was reviewed.
        2. Has been previously reported and reviewed, release the result and document in lab comments when it was last reviewed and by whom.
        3. Has never been reported or not reviewed within the past 90 days, perform a manual differential to see if the eosinophil or basophil count match the automated one.

            ● If the manual count matches, report the automated differential.

            ● If the counts do not match, report the manual differential. Pathologist review is only necessary if the absolute value criteria are met.

  1. Platelets
    If an “R” displays next to the platelet count or MPV result then a best fit curve was not generated. If the result does not require review for any other reason, then it can be reported.
    1. Action: <50 or >1000 (x103 cells/µl)
      1. Release result from LH to CLICS.
      2. Check Web Inquiry to see if the patient was previously reviewed by a pathologist.
        1. Has been previously reviewed in the past 90 days, release the result and document in Lab Comments when it was reviewed and by whom.
        2. Has been previously reviewed but >90 days since last review, perform a tech review and platelet estimate. If the estimate agrees, release the result and enter in Lab Comments: “Platelet count verified, platelet estimate = ______.”). If the estimate does not agree, check for platelet clumps and RBC fragments (schistocytes) and refer to VI.1.
        3. Has not been reviewed by a pathologist, perform a platelet estimate, if the platelet estimate agrees release the platelet hold the MPV results, and leave for pathologist review the first time only.
    2. Action: 50-99 (x103 cells/µl)
      1. Release result from LH to CLICS.
      2. Check Web Inquiry to see if the patient was reviewed within the last 90 days.
        1. Has been previously reviewed, release the result and document in Lab Comments when it was last reviewed and by whom.
        2. Has not been previously reviewed, perform a platelet estimate. If the estimate agrees, release the result and enter in Lab Comments: “Platelet count verified, platelet estimate = ______.”). If the estimate does not agree, check for platelet clumps and RBC fragments (schistocytes) and refer to VI.1.
  2. Hemoglobin
    Action: >20.0 g/dl (Adults >12 yrs)
    1. Release result from the LH to CLICS
    2. Check Web Inquiry to see if the patient was reviewed within 90 days.
      1. Has been previously reviewed, release the result and document in Lab Comments when it was last reviewed and by whom.
      2. Has not been reviewed, perform a tech review for any abnormal RBC morphology. Refer to Appendix A for RBC morphology review criteria. Leave for Pathologist Review the first time only.
    3. 1+ Hypo – not reviewed or reported, delete flag
    4. 2+ Hypo – reported, but does not require review
  3. MCV
    Note: On Neonates (<4 weeks old) MCV results are not reviewed on a PBS. Delete the macro flag on neonates.
    1. Action: <65 fL or >115 fL (>12 yrs) – 2+Micro and 2+Macro flags will be present, report.
      1. Release result from LH to CLICS.
      2. Check Web Inquiry to see if the patient was reviewed within 90 days.
        1. Has been previously reviewed, release the result and document in Lab Comments when it was last reviewed and by whom.
        2. Has not been previously reviewed, perform a tech review and refer to Appendix A for RBC morphology review criteria.
      3. 1+ Micro, 1+ Macro – not reviewed, but do report the flag.
    2. Action: Any value that fails a check:
      Verify specimen integrity and identity. Consult pathologist as necessary.
  4. MCHC
    Action: >39 g/dl
    1. Release result from LH to CLICS.
    2. Check Web Inquiry to see if the patient was reviewed within 90 days.
      1. Has been previously reviewed, release the result and document in Lab Comments when it was last reviewed and by whom.
      2. Has not been previously reviewed; make a slide and check for agglutination, severe Rouleaux, and spherocytes. If seen, refer to Pathologist as stated in Appendix A.
    3. Verify sample integrity; check for lipemia and hemolysis.
      1. If the specimen is lipemic refer to “Hemoglobin Correction for Lipemia” procedure and correct for the appropriate indices. Add the disclaimer “Specimen is lipemic”.
      2. If the specimen is hemolyzed, refer to the “Specimen Integrity; Hematology” section of the QA Manual, consult with a pathologist, and add the disclaimer “Specimen is hemolyzed”.
  5. RDW
    Action: >20%
    1. Release result from LH to CLICS.
    2. Check Web Inquiry to see if the patient was reviewed within 90 days.
      1. Has been previously reviewed, release the result.
      2. Has not been previously reviewed, perform a tech review and refer to Appendix A for RBC morphology criteria.

VI. Suspect Messages

  1. Platelet Clumps
    Action: Check specimen for a clot, if a clot is detected, have specimen redrawn. If no clot detected, repeat test on same specimen if possible.
    1. If the flag does not repeat, report results.
    2. If flag repeats, do not report platelet count or the MPV. Perform a tech review for platelet clumps, or platelet satellitism.
    3. Scan the peripheral edges of the blood film at 10X, if platelet clumps are not identified, rescan the feathered edge at 20X (confirm any suspicious looking clumps at 100X if necessary since some fibrin clumps may contain faint Platelet clusters); if platelet clumps are still not identified, randomly view 10 oil immersion fields, 100X.
      1. If no platelet clumps or satellitism are seen, review the PBS for other causes for the platelet clump flag, such as fragmented red cells or small red cells. Refer to Appendix A for RBC morphology criteria.
      2. If platelet clumps are seen only at 100X (usually only a few or you will see them on 10-20X), then report the platelet count and add the Lab Comment ”few platelet clumps are present”. (”few” platelets = less than one platelet clump per 100X field, and not more than five clumps with greater than 10 platelets in a clump.)
      3. If there are many clumped platelets seen at 100X, or if platelet clumps are identified at 10-20X, delete the platelet count and MPV from the CBC and report as indicated below.
        1. If the platelet estimate is 9-24/OIF enter the Canned Comment “Platelets appear normal to increased in number” in the Report Comment field of CLICS.
        2. If the platelet estimate is >24/OIF enter the Canned Comment “Platelets appear increased in number” in the Report Comment field of CLICS.
        3. If the platelet estimate is <9/OIF enter the Canned Comment “Platelets appear decreased in number. Enter “Suggest repeat sample” in the Report Comment field of CLICS. Check with a pathologist to see if a fresh EDTA and sodium citrate should be drawn.
          Note: If a citrate sample was requested, multiply the raw platelet count by 1.1 to correct for the citrate dilution. Enter the comment “Platelet count corrected for EDTA clumping.”
  2. Giant Platelets: When giant platelets are detected, PLT, MPV, PCT, and PDW may display with an R flag. A giant platelet is ≥ the size of a normal red cell.
    Action: Release result to CLICS and check to see if previously reported.
    1. Has been previously reported, then report the results by adding the canned comment “Giant Platelets present” to the Report Comment field.
    2. Has not been previously reported, perform a tech review. (2+ = 2/OIF)
      1. If <2+ Giant platelets are seen, do not report. Enter into Lab Comments “PBS was reviewed for giant platelets____seen/oif.
      2. If ≥ 2+ Giant Platelets are seen, add “2+ Giant Platelets” to the Report Comments field and leave for pathologist review first time only.
  3. NRBCs (Nucleated Red Blood Cells)
    Action: Any time this message is seen:
    1. Release the result to CLICS.
    2. Perform a tech review for NRBC’s. Record the # NRBC/100 WBC.
      1. If NRBC ≥ 6/100 WBC, correct the WBC. Refer to “WBC; Correcting for Nucleated RBC and Megakaryocytes.” Report number of NRBC’s seen in Reported Comments.
      2. If ≥ 30 NRBC (0-1 wk. old), ≥ 6 NRBC/100 WBC (1-4 wks. old) or ≥ 1 NRBC/100 WBC (>4 wks old):
        1. Check Web Inquiry to see if the patient was reviewed by pathologist.
        2. Has been previously reviewed, correct for WBC if necessary, and report the number of NRBC’s seen in Report Comments.
        3. Has not been previously reviewed, leave for pathologist review first time only.
  4. Cellular Interference: WBC histogram has interference at the 35fl region.
    On the LH750, when separation between the WBC populations is poorly defined on the histogram, WBC correction will be performed by the instrument and the “corrected WBC” will be listed as the WBC parameter. The “corrected WBC” may have an R flag. The uncorrected WBC (uWBC) will be listed in the comments section of the LH instrument report.
    Action: Perform a tech review for NRBCs or platelet clumps.
    1. If neither of these are seen and the WBC estimate agrees, report the corrected WBC results.
    2. If NRBCs are seen, refer to VI.3. NRBCs.
    3. If platelet clumps are seen, refer to VI.1. Platelet Clumps.
  5. For the following Diff Messages:
    IMM/NE2: Immature neutrophil 2 – Bands, Metas, Myelocytes, Promyelocytes.
    LY Blast: Suspect blasts in the lymphocyte area of the dataplot.
    MO Blast: Suspect blasts in the monocyte area of the dataplot.
    NE Blast: Suspect blasts in the neutrophil area of the dataplot.
    Variant LY: Variant Lymphocytes.
    Verify Diff: Unexpected data pattern or >20% Monocytes.
    1. Release result from the LH to CLICS
    2. Perform a manual differential.
      1. If no immature or abnormal cells are seen, no further review is necessary. Report the manual differential.
      2. If there are immature or abnormal cells seen, proceed to step C.
    3. Check Web Inquiry to see if the patient was previously reviewed.
      1. Has been previously reviewed and results match the previous, release the manual results and document when it was last reviewed and by whom.
      2. Has been previously reviewed, but new criteria from Appendix B are met for the first time, or the results change by more than 2 fold, hold the differential and leave for pathologist review.
      3. Has not been reviewed and criteria are met from Appendix B, hold the differential and leave for pathologist review.
  6. WBC Exceeds Linearity: Make 1:3 dilution with LH Diluent and re-assay. Program the dilution factor and run in the manual mode as a prediluted sample. Refer to V.1. for review criteria.
  7. Abnormal Retic Pattern: If this occurs in conjunction with a WBC >50 x 103 cells/μl, pathologist review is required.
  8. The following messages require no action to be taken:
    IMM/NE1 (LH 500 only)
    Abnormal Retic Pattern or Verify Retic (LH 750 only)
    Dimorphic Reds
    High WBC Count
    Low Event #
    RBC Interference
    Red Cell Agglutination

VII. Instrument Flags:

  1. H&H Check Fail: This flag occurs when the following calculation is not correct: Hgb x 3 = Hct (+/-3).
    Action: Rerun the sample
    1. If the error does not reoccur, report the instrument results.
    2. If the error occurs on the repeat:
      1. Check the sample for lipemia. Refer to “Hemoglobin Correction for Lipemia” procedure.
      2. Check for a high WBC count. Refer to “Hemoglobin Corrections for High WBC” procedure.
      3. Review the other RBC indices and consider a cold agglutinin, hemolysis or Rouleaux.
        1. If a cold agglutinin is suspected, refer to the “Cold Agglutinin Artifact in Hematology Analysis” procedure.
        2. If the sample is hemolyzed, refer to the “Specimen Integrity; Hematology” section of the QA Manual.
        3. If Rouleaux is suspected, make a PBS and review the slide. If marked Rouleaux is detected, refer to Appendix A.
      4. If no other messages indicated a problem with the sample or results, and the sample itself appears fine, report the results.
  2. For all other Instrument Flags, refer to the LH 750, Beckman Coulter; Operate or LH 500, Beckman Coulter; Operate procedures.

VIII. Differential Review:

Manual Peripheral Blood Smear result entry in CLICS: for CBC with Differential and WBC with Differential. Currently this screen is not available for Hemogram, Hemoglobin & Hematocrit or Platelet Count.
Note: This feature is available in Manual Result Entry, Transcription Result Review/Release and Interfaced Instrument Result Review/Release screens.

  1. Click on the Manual PBS button.
  2. Enter the manual differential results in the “Differential Formed Elements” table.
    The number of cells must add up to 100. There is a counter below the “Differential Formed Elements” table that adds the cell types as they are entered.
  3. Enter formed element results in the “Named Formed Elements” table. The appropriate text values for the selected formed element will appear below the “Named Formed Elements” table with the exception of NRBC, Platelet Estimate, Plasma Cells and Variant Lymphs, which require entry of an absolute number.
    Refer to the table “Manual
    PBS Named Formed Element Reporting” for the acceptable reporting criteria.
  4. If the instrument differential is to be reported, select the “Accept Instrument Diff” button.
    1. Select OK to return to the Result Review/Release screen.
    2. The manual differential results will be displayed in the Lab Comments field. The Named Formed Elements will be displayed in the Report Comments field.
    3. Enter the Left Shift result if appropriate.
    4. Enter in Lab Comments the reason for review, example: Held for IMM NE2. Enter the date of the last pathology review if applicable.
    5. Enter applicable Report Comments.
    6. Enter “reviewed by operator initials” following the text in the Lab Comments, and/or Report Comments field.
    7. Enter asterisks before and after the text in the Lab Comments field. This is done to differentiate non-germane nurses notes from lab comments.
  5. If the manual differential is to be reported, select the “Accept Manual Diff” button.
    1. Select OK to return to the Result Review/Release screen.
    2. The manual differential results will replace the instrument differential results. The lymphocyte cell types will be added together and reported in the Lymphocyte field. The neutrophil cell types will be added together and reported in the Neutrophil field.
    3. The manual differential results and named formed elements will be displayed in the Report Comments field. This is done in order to report the complete differential including all immature cell types.
    4. The Absolute Neutrophil will be recalculated.
    5. Enter the Left Shift result if appropriate.
    6. Enter in Lab Comments the reason for review, example: Held for IMM NE2. Enter the date of the last pathology review if applicable.
    7. Enter applicable Report Comments.
    8. Enter “reviewed by operator initials” following the text in the Lab and Report Comments fields.
    9. Enter asterisks before and after the text in the Lab Comments field. This is done to differentiate non-germane nurses notes from lab comments.
  6. If Pathologist Review is required, select the “Hold for further review” button.
    1. Select OK to return to the Result/Review/Release screen. The results listed in Differential Formed Elements and Named Formed Elements will remain in the tables until results are finalized. The results from both tables will be listed in Lab Comments.
    2. Hold results to be reviewed by a pathologist.
    3. When review is complete, click on the “Manual PBS” button.
    4. Edit the results in the Manual PBS screen if required.
    5. Select either “Accept Instrument Diff” or “Accept Manual Diff”. Refer to these sections.
    6. The first entry to Lab Comments will need to be edited so duplicate comments do not appear.

Manual PBS Named Formed Element Reporting

Named Formed Element

Acceptable Values

Acanthocytes

1+, 2+

Auer Rods

Present

Anisocytosis

1+, 2+

Basophilic Stippling

Present

Dohle Bodies

Present

Giant Platelets

1+, 2+

Howell-Jolly Bodies

Present

Hypersegmented PMN

Present

Hypogranular PMN

Present

Megakaryocytes

Present

Microorganisms

Present

Neutrophilic Vacuolization

Present

NRBC

#/100 WBC

Pappenheimer Bodies

Present

Pelger-Huet

Present

Plasma Cells

#

Platelet Clumps

Present

Platelet Estimate

#/OIF

Poikilocytosis

1+, 2+

Polychromasia

1+, 2+

Rouleaux

Present

Schistocytes

1+, 2+

Sickle Cells

Present

Smudge Cells

Present

Spherocytes

1+, 2+

Target Cells

1+, 2+

Teardrop Cells

1+, 2+

Toxic Granulation

Present

Variant Lymphs

#

IX. Competency:

  1. A survey/proficiency test is examined 3 times per year by the Hematology staff. One hematology tech will examine and result the survey. After the survey deadline date, the rest of the hematology staff will examine the slides. Results are compared to the survey results and reviewed by the staff and pathologist.
  2. All lab personnel reporting CBCs or WBC differentials will complete one in-house QC slide quarterly. The differential, WBC estimate and platelet estimate must agree within 25% of the mean of the Hematology staff or automated count. Any person failing the QC differential, estimates, or RBC morphology must repeat their differential and/or estimate and review the smear with a supervisor. All QC differential reports are kept on file and reviewed by the supervisor.

X. Quality Control:

A representative slide from each batch of slides stained is examined to ensure the staining procedure has provided a stained smear that is consistent as well as correctly stained with respect to color intensity and cellular detail, and free of precipitate. Poorly made or stained smears are remade and re-examined. Refer to the “Peripheral Blood Smear Examination” procedure for instructions on proper technique for reviewing a slide.

 

  1. October 2006 L. McGovern (Revised: II.5., IV.8 and VI.7. added)
  2. February 2007 L. McGovern (Revised: II.5.C.; IV.1.C.; II.3.)
  3. August 2008 L. McGovern (Revised: V.5. added)
  4. August 2009 L. McGovern, M. English (Revised: V.5. for addition of mpbs screen in CLICS)
  5. February 2011 S. Dunn, L. McGovern (Revised: protocol reorganized; slide exam & appendices added; V. revised wbc <3.0, plt <50, hgb >20, mcv <65 >115, mchc >39, rdw >20)
  6. November 2011 L. McGovern (Revised: VI.7. Abn Retic Pat with >50 WBC)

 

Comprehensive Review:

Pathologist:

Technical Director:

 

Interim Review: February 2012 L. McGovern (Revised: V.1.note)

Appendix A

Graded Red Cell Morphology

Morphology

Grading Criteria

Pathologist Review, first time seen.

1+ Schistocytes

1-2/ OIF

Yes

2+ Schistocytes

≥ 3/OIF

Yes

     

1+ Spherocytes

1-2/OIF

No

2+ Spherocytes

≥ 3/OIF

Yes

     

1+ Tear Drop cells

1-2/OIF

No

2+ Tear Drop cells

≥ 3/OIF

Yes

     

1+ Acanthocytes

1-2/OIF

No

2+ Acanthocytes

≥ 3/OIF

Yes

     

1+ Target cells

1-2/OIF

No

2+ Target cells

≥ 3/OIF

Yes

     

1+ Polychromasia

2-3/OIF

No

2+ Polychromasia

≥ 4/OIF

Yes (except for newborns)

     

1+ Giant Platelets

< 2/OIF

No - do not report

2+ Giant Platelets

≥ 2/OIF

Yes - reported

     

Ungraded Red Cell Morphology – Report as Present when seen.

Morphology

Pathologist Review, first time seen.

Mild non-specific Poikilocytosis: Use when several types of cells are seen, adding up to 5 or more/OIF, but specific criteria are not met.

No (Do not use in combination with specific types of cells.

Basophilic Stippling

No

Howell-Jolly Bodies

No

Pappenheimer Bodies

No

Megakaryocytes

Yes

Rouleaux

Yes

Sickle Cells

Yes

Any other inclusion (ie. Microorganism)

Yes

Appendix B

WBC

Release result

Leave for Path Review

Band

Refer to the procedure Band Cells and Immature Neutrophils, Criteria for to identify bands.

≤ 30%

Add to Left Shift field:

1+ (9-20 bands)

2+ (>20 bands)

> 30 %

Metamyelocyte

≤ 5%

>5%

Myelocyte

≤ 5%

>5%

Promyelocyte

 

Any

Blast

 

Any

Variant Lymphocyte

(Plasmacytoid & Reactive)

≤ 10%

> 10%

Plasma Cells

≤ 3%

>3%

Large Unclassified Cells

 

Any

Any unidentifiable cell

(ie. Sezary Cell, Hairy Cell)

 

Any

Absolute (#) values for the WBC parameters: Pathologist review first time only.

Neutrophils #: <1.0 or >20.0

Lymphocytes #: >5.0 (>12yrs); >7.0 (≤ 12yrs)

Monocytes #: >1.5 (>12yrs); >3.0 (≤ 12yrs)

Eosinophils #: >2.0

Basophils #: >0.5

Report as Present when seen (Reported Comments):

- Auer Rods

- Toxic Granulation

- Dohle Bodies

- Neutrophilic Vacuolization

- Pelger-Huet = count as segmented neutrophils, but add to Reported Comments

- Hypogranular Neutrophils

- Hypersegmented Neutrophils

- Smudge Cells seen.

Appendix C

 

For Medical Associates’ Oncology Patients

  1. A PBS review by a Technologist is only required when the following flags are seen:
    1. Verfity Diff
    2. Platelet Clumps
    3. Giant Platelets
    4. Cellular Interference
    5. NRBC
    6. H&H Check Fail
    7. Instrument flags such as: ----, ++++, …. and ::::
      When any of these flags occur, check Web Inquiry to review patient history. Hold for Pathologist review as required.
  2. A critical platelet count is <10 x 103. (All results <30 will be flagged on the instrument as critical values since only one set of critical values can be programmed for a parameter.)
  3. Technologist review for platelet counts <100 x 103:
    1. Review first time <100.
    2. Does not need to be reviewed again unless it goes above 100 and then drops back below 100.
    3. Each time, document in Lab Comments when it was last reviewed and by whom.

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