master laboratory checklist limited service

Master

Limited ServiceLaboratory Checklist

CAP Accreditation Program

College of American Pathologists325 Waukegan RoadNorthfield, IL 60093-2750www.cap.org 06.04.2020

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Limited Service Laboratory Checklist 06.04.2020

Disclaimer and Copyright NoticeOn-site inspections are performed with the edition of the Checklists mailed to a facility at the completionof the application or reapplication process, not necessarily those currently posted on the website. Thechecklists undergo regular revision and a new edition may be published after the inspection materialsare sent.

For questions about the use of the Checklists or Checklist interpretation, email [email protected] or call800-323-4040 or 847-832-7000 (international customers, use country code 001).

The Checklists used for inspection by the College of American Pathologists' Accreditation Programshave been created by the CAP and are copyrighted works of the CAP. The CAP has authorized copyingand use of the checklists by CAP inspectors in conducting laboratory inspections for the Commissionon Laboratory Accreditation and by laboratories that are preparing for such inspections. Except aspermitted by section 107 of the Copyright Act, 17 U.S.C. sec. 107, any other use of the Checklistsconstitutes infringement of the CAP's copyrights in the Checklists. The CAP will take appropriate legalaction to protect these copyrights.

All Checklists are ©2020. College of American Pathologists. All rights reserved.

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Limited Service LaboratoryChecklist

TABLE OF CONTENTS

SUMMARY OF CHANGES....................................................................................................................5INTRODUCTION.................................................................................................................................... 8

DEFINITION AND USE........................................................................................................................................................8ATTESTATION.....................................................................................................................................................................8

QUALITY MANAGEMENT AND QUALITY CONTROL........................................................................9GENERAL ISSUES..............................................................................................................................................................9QUALITY CONTROL AND CALIBRATION – WAIVED TESTS.......................................................................................... 9QUALITY CONTROL - NONWAIVED TESTS...................................................................................................................11

HEMATOLOGY SECTION...................................................................................................................15SPECIMEN COLLECTION AND HANDLING....................................................................................................................15COMPLETE BLOOD COUNT (CBC) INSTRUMENTS..................................................................................................... 17

CBC INSTRUMENT CALIBRATION........................................................................................................................... 17Commercial Calibrators.........................................................................................................................................18

CBC INSTRUMENT QUALITY CONTROL................................................................................................................. 19Stabilized Controls................................................................................................................................................ 20Moving Averages...................................................................................................................................................20Retained Patient Specimens.................................................................................................................................22Error Detection and Verification............................................................................................................................22

MANUAL HEMATOCRIT....................................................................................................................................................26MANUAL BLOOD COUNT.................................................................................................................................................27AUTOMATED DIFFERENTIALS........................................................................................................................................28MANUAL DIFFERENTIALS............................................................................................................................................... 30AUTOMATED RETICULOCYTES......................................................................................................................................32MANUAL RETICULOCYTES............................................................................................................................................. 33ABNORMAL HEMOGLOBIN DETECTION........................................................................................................................34BONE MARROW PREPARATIONS..................................................................................................................................34RESULTS REPORTING - HEMATOLOGY....................................................................................................................... 35

COAGULATION SECTION..................................................................................................................36SPECIMEN COLLECTION AND HANDLING - COAGULATION...................................................................................... 36QUALITY CONTROL - COAGULATION........................................................................................................................... 42COAGULATION TESTS BASED ON DIRECT MEASUREMENT OF ANALYTES........................................................... 43COAGULATION STUDIES.................................................................................................................................................48

PT/INR AND aPTT...................................................................................................................................................... 48D-DIMER STUDIES.....................................................................................................................................................52FIBRINOGEN (EXCLUDING IMMUNOLOGIC METHODS)........................................................................................54

CHEMISTRY SECTION....................................................................................................................... 56SPECIMEN HANDLING - CHEMISTRY............................................................................................................................ 56CALIBRATION AND VERIFICATION PROCESSES - NONWAIVED TESTS - CHEMISTRY.......................................... 57CONTROLS - NONWAIVED TESTS - CHEMISTRY........................................................................................................ 63RESULTS REPORTING.................................................................................................................................................... 64GENERAL CHEMISTRY....................................................................................................................................................65ANTI-NUCLEAR ANTIBODY TESTING - CHEMISTRY....................................................................................................66HIV PRIMARY DIAGNOSTIC TESTING - CHEMISTRY...................................................................................................66BLOOD GAS ANALYSIS................................................................................................................................................... 67

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SPECIMEN COLLECTION AND HANDLING - BLOOD GAS.....................................................................................67BLOOD GAS INSTRUMENTS.................................................................................................................................... 68

HEMOGLOBIN SEPARATION...........................................................................................................................................70COLORIMETERS, SPECTROPHOTOMETERS, AND FLUORIMETERS........................................................................ 71THERAPEUTIC DRUG MONITORING..............................................................................................................................72

URINALYSIS AND CLINICAL MICROSCOPY SECTION.................................................................. 74SPECIMEN COLLECTION AND HANDLING - URINALYSIS........................................................................................... 74CALIBRATION AND STANDARDS - NONWAIVED TESTS - URINALYSIS.................................................................... 75PROCEDURES AND TEST SYSTEMS............................................................................................................................ 77URINALYSIS - MANUAL MICROSCOPY..........................................................................................................................78AUTOMATED AND SEMI-AUTOMATED SYSTEMS........................................................................................................79

DIPSTICK READERS..................................................................................................................................................79AUTOMATED MICROSCOPY SYSTEMS.................................................................................................................. 80

BODY FLUIDS SECTION....................................................................................................................82MANUAL CELL COUNT - BODY FLUID...........................................................................................................................82AUTOMATED CELL COUNT - BODY FLUID................................................................................................................... 83NUCLEATED CELL DIFFERENTIALS - BODY FLUID.....................................................................................................84SEMEN ANALYSIS............................................................................................................................................................87

REQUISITIONS, SPECIMEN RECEIPT AND RESULTS REPORTING.....................................................................88SPERM MOTILITY...................................................................................................................................................... 89STAINED SMEAR - SPERM DIFFERENTIAL............................................................................................................ 91AUTOMATED SEMEN ANALYSIS INSTRUMENTS...................................................................................................93

MICROBIOLOGY SECTION................................................................................................................ 96SPECIMEN COLLECTION AND HANDLING - MICROBIOLOGY.................................................................................... 96REPORTING OF RESULTS............................................................................................................................................ 102INSTRUMENTS AND EQUIPMENT - MICROBIOLOGY................................................................................................ 102MEDIA.............................................................................................................................................................................. 103DIRECT SPECIMEN EXAMINATION.............................................................................................................................. 104

MOLECULAR-BASED MICROBIOLOGY TESTING-WAIVED TESTS (MICROBIOLOGY)......................................107STAINS...................................................................................................................................................................... 108

BIOSAFETY..................................................................................................................................................................... 110

IMMUNOLOGY SECTION................................................................................................................. 113CALIBRATION AND STANDARDS - NONWAIVED TESTS...........................................................................................113CONTROLS - NONWAIVED TESTS...............................................................................................................................118ANTI-NUCLEAR ANTIBODY TESTING (IMMUNOLOGY).............................................................................................. 119BLOOD TYPE, GROUP, AND/OR ANTIBODY SCREENS.............................................................................................119SYPHILIS SEROLOGY....................................................................................................................................................123HIV PRIMARY DIAGNOSTIC TESTING - IMMUNOLOGY.............................................................................................125DIRECT ANTIGEN TESTING.......................................................................................................................................... 126MOLECULAR-BASED MICROBIOLOGY TESTING - WAIVED TESTING (IMMUNOLOGY)......................................... 128

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ON-LINE CHECKLIST AVAILABILITY AND RESOURCES

Participants of the CAP accreditation programs may download the checklists from the CAP website (cap.org)by logging into e-LAB Solutions Suite. They are available in different checklist types and formatting options,including:

● Master — contains ALL of the requirements and instructions available in PDF, Word/XML or Excelformats

● Custom — customized based on the laboratory's activity (test) menu; available in PDF, Word/XML orExcel formats

● Changes Only — contains only those requirements with significant changes since the previous checklistedition in a track changes format to show the differences; in PDF version only. Requirements that havebeen moved or merged appear in a table at the end of the file.

A repository of questions and answers and other resources is also available in e-LAB Solutions Suite underAccreditation Resources, Checklist Requirement Q & A.

SUMMARY OF CHECKLIST EDITION CHANGESLimited Service Laboratory Checklist

06/04/2020 Edition

The information below includes a listing of checklist requirements with significant changes in the current editionand previous edition of this checklist. The list is separated into three categories:

1. New2. Revised:

● Modifications that may require a change in policy, procedure, or process for continuedcompliance; or

● A change to the Phase3. Deleted/Moved/Merged:

● Deleted● Moved — Relocation of a requirement into a different checklist (requirements that have been

resequenced within the same checklist are not listed)● Merged — The combining of similar requirements

NOTE: The requirements listed below are from the Master version of the checklist. The customized checklistversion created for on-site inspections and self-evaluations may not list all of these requirements.

NEW Checklist Requirements

Requirement Effective DateLSV.38707 09/17/2019LSV.38744 09/17/2019LSV.38748 09/17/2019LSV.39510 06/04/2020LSV.39520 06/04/2020LSV.39530 06/04/2020LSV.40575 09/17/2019LSV.41341 09/17/2019LSV.41343 09/17/2019LSV.41346 06/04/2020LSV.41815 06/04/2020LSV.44620 06/04/2020LSV.45560 06/04/2020LSV.45740 09/17/2019

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LSV.45745 09/17/2019LSV.46087 09/17/2019LSV.46240 09/17/2019LSV.46571 09/17/2019LSV.46572 09/17/2019LSV.47050 06/04/2020LSV.48475 09/17/2019LSV.48485 09/17/2019LSV.48495 09/17/2019LSV.48505 09/17/2019

REVISED Checklist Requirements

Requirement Effective DateLSV.37079 09/17/2019LSV.37082 09/17/2019LSV.37100 09/17/2019LSV.37370 09/17/2019LSV.37650 09/17/2019LSV.37660 06/04/2020LSV.37680 06/04/2020LSV.37700 06/04/2020LSV.37740 09/17/2019LSV.38540 09/17/2019LSV.38664 09/17/2019LSV.38667 09/17/2019LSV.38690 06/04/2020LSV.38743 09/17/2019LSV.38745 09/17/2019LSV.38750 09/17/2019LSV.38910 09/17/2019LSV.39236 09/17/2019LSV.40130 09/17/2019LSV.40210 09/17/2019LSV.40530 09/17/2019LSV.40610 09/17/2019LSV.42050 06/04/2020LSV.42290 06/04/2020LSV.42370 06/04/2020LSV.42375 09/17/2019LSV.42380 09/17/2019LSV.43250 09/17/2019LSV.43746 09/17/2019LSV.43848 09/17/2019LSV.44394 09/17/2019LSV.44610 06/04/2020LSV.44690 09/17/2019LSV.44785 09/17/2019LSV.45297 09/17/2019LSV.45390 09/17/2019LSV.45900 09/17/2019LSV.46070 09/17/2019LSV.46075 09/17/2019LSV.46080 09/17/2019LSV.46090 09/17/2019

DELETED/MOVED/MERGED Checklist Requirements

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Requirement Effective DateLSV.02200 09/16/2019LSV.02500 09/16/2019LSV.02525 09/16/2019LSV.02600 09/16/2019LSV.02700 09/16/2019LSV.02800 09/16/2019LSV.02820 09/16/2019LSV.35610 09/16/2019LSV.35640 09/16/2019LSV.35670 09/16/2019LSV.35700 09/16/2019LSV.37240 09/16/2019LSV.37280 09/16/2019LSV.37300 09/16/2019LSV.37330 09/16/2019LSV.37390 09/16/2019LSV.37480 09/16/2019LSV.37500 09/16/2019LSV.38730 09/16/2019LSV.38740 09/16/2019LSV.43864 06/03/2020LSV.45315 06/03/2020LSV.45320 06/03/2020

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INTRODUCTION

This checklist is used in conjunction with the All Common and Laboratory General Checklists to inspect a limitedservice laboratory.

Certain requirements are different for waived versus nonwaived tests. Refer to the checklist headings andexplanatory text to determine applicability based on test complexity. The current list of tests waived under CLIAmay be found at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/analyteswaived.cfm.

Laboratories not subject to US regulations: Checklist requirements apply to all laboratories unless a specificdisclaimer of exclusion is stated in the checklist. When the phrase "FDA-cleared/approved test (or assay)" isused within the checklist, it also applies to tests approved by an internationally recognized regulatory authority(eg, CE-marking).

DEFINITION AND USE

The Limited Service Laboratory (LSV) Checklist may be used for medical or clinical laboratories whose scopeof offered services includes basic, commonly performed laboratory tests or procedures in multiple disciplines.The checklist is typically used for a satellite lab, stat lab, outpatient clinic, emergency service, or special functionlaboratory.

The use of the LSV Checklist is restricted to a subset of tests under the following disciplines: chemistry,hematology, urinalysis, immunology, and microbiology. If a scope of service in a particular discipline exceedsthose addressed in this checklist, a separate section-specific checklist is required for that discipline. TheLaboratory Accreditation Program makes the final determination regarding the use of this checklist. Commonexamples of services exceeding the use of this checklist include the following:

● Coagulation factor assays and platelet aggregation studies in hematology● Culture/sensitivity and molecular infectious disease testing in microbiology● Chromatography, electrophoresis, and cystic fibrosis sweat testing in chemistry● Western blot testing and pre-transfusion immunohematological testing in immunology

The LSV Checklist CANNOT be used to inspect anatomic pathology, cytopathology, flow cytometry, molecularpathology, histocompatibility, cytogenetics, or point-of-care testing. Section-specific checklists must be usedfor each of those disciplines. Laboratories storing and issuing blood components must use the TransfusionMedicine Checklist.

The LSV Checklist utilizes requirements already in existing section-specific checklists (eg, hematology,chemistry, microbiology, etc.). Only slight editorial changes have been made for the sake of maintaining context.In summary, this checklist does not represent any compromise of CAP Standards for accreditation or differencewith respect to CLIA regulatory requirements.

Additional information on inspection of limited service laboratories can be found in the Laboratory AccreditationManual.

ATTESTATION

This Limited Service Laboratory Checklist is not valid for a College of American Pathologists inspection unlessit is used for the purpose intended. If there is any doubt, inspectors should contact the CAP Central Office toconfirm appropriate usage of the checklist. The laboratory director and inspector's signatures on the Inspector's

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/analyteswaived.cfm

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Summation Report confirm that they are in mutual agreement that the laboratory concerned meets the criteriafor use of the Limited Service Laboratory Checklist.

QUALITY MANAGEMENT AND QUALITY CONTROL

Checklist requirements under the Quality Management and Quality Control section apply to all areas of thelimited service laboratory. Additional discipline-specific requirements are found in the other areas of the checklistand are to be used in conjunction with this section.

GENERAL ISSUES

Inspector Instructions:

● Sampling of QC records for monthly review

LSV.00900 Monthly QC Review Phase II

Quality control data are reviewed and assessed at least monthly by the laboratory directoror designee.

NOTE: The review of quality control data must be recorded and include follow-up for outliers,trends, or omissions that were not previously addressed.

The QC data for tests performed less frequently than once per month should be reviewed whenthe tests are performed.

The review of quality control data for tests that have an IQCP approved by the laboratory directormust include an assessment of whether further evaluation of the risk assessment and qualitycontrol plan is needed based on problems identified (eg, trending for repeat failures, etc.).

Evidence of Compliance:✓ Records of QC review including follow-up for outliers, trends or omissions

QUALITY CONTROL AND CALIBRATION – WAIVED TESTS


● Sampling of calibration/calibration verification policies and procedures● Sampling of calibration/calibration verification records● Sampling of quality control policies and procedures● Sampling of QC records

● What is your course of action if calibration is unacceptable?● When was the last time you performed a calibration procedure and how did you verify

the calibration?

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● How do you determine when QC is unacceptable and when corrective actions areneeded?

● Further evaluate the responses, corrective actions, and resolutions for unacceptablecalibration, and unacceptable calibration verification

● Review a sampling of QC data over the previous two-year period. Select severaloccurrences in which QC is out of range and follow records to determine if the stepstaken follow the laboratory procedure for corrective action

LSV.37064 Calibration, Calibration/Verification - Waived Tests Phase II

Testing personnel follow manufacturer's instructions for calibration, calibrationverification, and related functions.

Evidence of Compliance:✓ Written procedure consistent with the manufacturer's instructions for each waived test AND✓ Records for calibration/calibration verification/related functions as required by the

manufacturer AND✓ Records of recalibration or other appropriate corrective action when calibration verification is

unacceptable

LSV.37068 QC - Waived Tests Phase II

The laboratory follows manufacturer's instructions for quality control, reviews results, andrecords acceptability prior to reporting patient results.

NOTE: Quality control must be performed according to manufacturer's instructions. To detectproblems and evaluate trends, testing personnel or supervisory staff must review quality controldata on days when controls are run prior to the reporting of results. The laboratory director ordesignee must review QC data at least monthly or more frequently if specified in the laboratoryQC policy.

With respect to internal controls, acceptable control results must be recorded, at a minimum,once per day of patient testing for each device.*

*Acceptable internal control results need not be recorded, if (and only if) an unacceptableinstrument control automatically locks the instrument and prevents release of patient results.

Evidence of Compliance:✓ Written procedure consistent with manufacturer's instructions for each waived test AND✓ Records showing confirmation of acceptable QC results

LSV.37072 QC Corrective Action - Waived Tests Phase II

There is a record of corrective action when control results exceed defined acceptabilitylimits.

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QUALITY CONTROL – NONWAIVED TESTS


● Sampling of quality control policies and procedures● Sampling of QC records, including external and internal quality control processes

● How do you determine when quality control is unacceptable and when correctiveactions are needed?

● How does your laboratory verify or establish acceptable quality control ranges?● What is your course of action when monthly precision data changes significantly from

the previous month’s data?● What is your course of action when you perform test procedures that do not have

commercially available calibration or control materials?


● Use QC data to identify tests that utilize internal quality control processes to confirmthat any individualized quality control plan (IQCP) is used as approved by thelaboratory director

LSV.37078 Daily QC - Nonwaived Tests Phase II

Controls are run at least daily, or more frequently if specified in manufacturer'sinstructions, laboratory procedure, or the CAP Checklist, for quantitative and qualitativetests, and when changes occur that may impact patient results.

NOTE: The laboratory must define the number and type of quality control used and the frequencyof testing in its quality control procedures. Control testing is not required on days when patienttesting is not performed.

Controls must be run prior to resuming patient testing when changes occur that may impactpatient results, including after a change of analytically critical reagents, major preventivemaintenance, change of a critical instrument component, or with software changes, asappropriate. Daily quality control must be run as follows:

1. Quantitative tests - two controls at different concentrations at least daily2. Qualitative tests - a negative control and a positive control (when applicable) at least

daily

Controls should verify assay performance at relevant decision points. The selection of thesepoints may be based on clinical or analytical criteria.

If an internal quality control process (eg, electronic/procedural/built-in) is used instead of anexternal control material to meet daily quality control requirements, the laboratory must have anindividualized quality control plan (IQCP) approved by the laboratory director. Please refer to theIQCP section of the All Common Checklist for the eligibility of tests for IQCP and requirementsfor implementation and ongoing monitoring of an IQCP.

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Evidence of Compliance:✓ Records of QC results including external and internal control processes AND✓ Written quality control procedures AND✓ Manufacturer product insert or manual

REFERENCES1) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare, Medicaid and CLIA programs;

CLIA fee collection; correction and final rule. Fed Register. 2003(Jan 24):5232 [42CFR493.1256(d)(3) (i, ii)], [42CFR493.1256(d)(6)].2) Steindel SJ, Tetrault G. Quality control practices for calcium, cholesterol, digoxin, and hemoglobin. A College of American

Pathologists Q-Probes study in 505 hospital laboratories. Arch Pathol Lab Med. 1998;122:401-4083) Clinical and Laboratory Standards Institute (CLSI). Statistical Quality Control for Quantitative Measurement Procedures: Principles

and Definitions; Approved Guideline. 4th ed. CLSI document C24-ED4. Clinical and Laboratory Standards Institute, Wayne, PA,2016.

4) Ye JJ, et al. Performance evaluation and planning for patient/client-based quality control procedures. Am J Clin Pathol.2000;113:240-248

5) Clinical and Laboratory Standards Institute (CLSI). User Protocol for Evaluation of Qualitative Test Performance; Approved Guideline—Second Edition. CLSI document EP12-A2 (ISBN 1-56238-654-9). Clinical and Laboratory Standards Institute, 940 West ValleyRoad, Suite 1400, Wayne, Pennsylvania 19087-1898 USA, 2008.

6) Clinical and Laboratory Standards Institute. Laboratory Quality Control Based on Risk Management; Approved Guideline. CLSIdocument EP23-A. Clinical and Laboratory Standards Institute, Wayne, PA, 2011.

7) Department of Health and Human Services, Centers for Medicare and Medicaid Services, Brochure #11. CLIA IndividualizedQuality Control Plan Introduction. July 2013. http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIAbrochure11.pdf

8) Centers for Medicare and Medicaid Services (CMS), Individual Quality Control Plan (IQCP) for Clinical Laboratory ImprovementAmendments (CLIA) laboratory nonwaived testing. http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/IQCP-announcement-letter-for-CLIA-CoC-and-PPM-labs.pdf (Accessed June 2014).

**REVISED** 09/17/2019LSV.37079 Fluorescent Antibody Stain QC Phase II

Positive and negative controls are included with each patient run for all fluorescentantibody stains (eg, ANA IFA).

Evidence of Compliance:✓ Written procedure for fluorescent antibody stain QC AND✓ Records of fluorescent antibody stain QC at defined frequency

REFERENCES1) Clinical and Laboratory Standards Institute. Assessing the Quality of Immunoassay Systems: Radioimmunoassays and Enzyme,

Fluorescence, and Luminescence Immunoassays; Approved Guideline. CLSI Document I/LA23-A. Clinical and Laboratory StandardsInstitute, Wayne, PA; 2004.

**REVISED** 09/17/2019LSV.37082 Control Range Establishment or Verification Phase II

An acceptable control range is established or verified for each lot of control material.

NOTE: For unassayed control materials, an acceptable control range must be established byrepetitive analysis in runs that include previously tested control material. For assayed controlmaterials, control ranges supplied by the manufacturer must be verified.

Control ranges supplied by the manufacturer may be used without verification for qualitative (eg,positive or negative) testing.

Evidence of Compliance:✓ Written procedure to establish or verify control ranges AND✓ Records for control range establishment or verification of each lot

REFERENCES1) Clinical and Laboratory Standards Institute. Evaluation of Precision Performance of Quantitative Measurement Methods; Approved

Guideline. 3rd ed. CLSI Document EP05-A3. Clinical and Laboratory Standards Institute, Wayne, PA; 2014.2) Clinical and Laboratory Standards Institute. Statistical quality control for quantitative Measurement Procedures: Principles and

Definitions; Approved Guideline. 4th ed. CLSI Document C24-A4. Clinical and Laboratory Standards Institute, Wayne, PA; 2016.

LSV.37084 Alternative Control Procedures Phase II

http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIAbrochure11.pdf

http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIAbrochure11.pdf

http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/IQCP-announcement-letter-for-CLIA-CoC-and-PPM-labs.pdf

http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/IQCP-announcement-letter-for-CLIA-CoC-and-PPM-labs.pdf

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If the laboratory performs test procedures for which control materials are notcommercially available, there are written procedures for an alternative mechanism todetect immediate errors and monitor test system performance over time. The performanceof alternative control procedures must be recorded.

NOTE: "Performance" includes elements of accuracy, precision, and clinical discriminatingpower. Examples of alternative procedures may include split sample testing with another methodor with another laboratory, the testing of previously tested patient specimens in duplicate, testingof patient specimens in duplicate, or other defined processes approved by the laboratory director.

Evidence of Compliance:✓ Written procedures for alternative quality control AND✓ Records of alternative control procedures

REFERENCES1) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvement

amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1256(h)].

LSV.37086 QC Data Phase II

Quality control data are organized and presented so they can be evaluated daily by thetechnical staff to detect problems, trends, etc.

NOTE: Results of controls must be recorded or plotted to readily detect a malfunction in theinstrument or in the analytic system. These control records must be readily available to theperson performing the test.

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Statistical Quality Control for Quantitative Measurement Procedures: Principles


LSV.37088 Numeric QC Data Phase I

For numeric QC data, quality control statistics (eg, SD and CV) are calculated monthly todefine and monitor analytic imprecision.

NOTE: The laboratory must evaluate the imprecision statistics (eg, SD and CV, or otherappropriate statistics) monthly to confirm that the test system is performing within acceptablelimits. For whole blood methods, where stabilized whole blood or other suitable material is notavailable for QC, such statistics may be generated from previous patient/client samples using theSD of duplicate pairs or other patient data based statistical procedures.

This checklist requirement does not apply to external controls run only to verify new lots/shipments of test materials. However, the laboratory should have defined acceptable limits forsuch controls (either from the manufacturer, or developed by the laboratory).

Evidence of Compliance:✓ Written procedure for monitoring analytic imprecision including statistical analysis of data

AND✓ QC records showing monthly monitoring for imprecision

REFERENCES1) Rifai N, Horvath AR, Wittwer CT, eds. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 6th ed. St. Louis, MO:

Elsevier; 2018.2) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvement

amendments of 1988; final rule. Fed Register. 2003(Jan 24):7146 [42CFR493.1256(d)(10)(i)]3) Ross JW, Lawson NS. Analytic goals, concentrations relationships, and the state of the art for clinical laboratory precision. Arch

Pathol Lab Med. 1995;119:495-5134) Clinical and Laboratory Standards Institute (CLSI). Statistical Quality Control for Quantitative Measurement Procedures: Principles


5) Brooks ZC, et al. Critical systematic error supports used of varied QC rules in routine chemistry. Clin Chem. 2000;46:A70

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LSV.37090 QC Corrective Action Phase II

There are records of corrective action when control results exceed defined acceptabilitylimits.

NOTE: Patient/client test results obtained in an analytically unacceptable test run or since the lastacceptable test run must be re-evaluated to determine if there is a significant clinical differencein patient/client results. Re-evaluation may or may not include re-testing patient samples,depending on the circumstances.

Even if patient samples are no longer available, test results can be re-evaluated to search forevidence of an out-of-control condition that might have affected patient results. For example,evaluation could include comparison of patient means for the run in question to historical patientmeans, and/or review of selected patient results against previous results to see if there areconsistent biases (all results higher or lower currently than previously) for the test(s) in question.

The corrective action for tests that have an IQCP approved by the laboratory director mustinclude an assessment of whether further evaluation of the risk assessment and quality controlplan is needed based on the problems identified (eg, trending for repeat failures, etc.).


amendments of 1988; final rule. Fed Register. 2003(Oct 1):1046[42CFR493.1282(b)(1)(i)]

LSV.37092 QC Handling Phase II

Control specimens are tested in the same manner and by the same personnel as patient/client samples.

NOTE: QC specimens must be analyzed by personnel who routinely perform patient/client testing- this does not imply that each operator must perform QC daily, so long as each instrument and/or test system has QC performed at required frequencies, and all analysts participate in QC on aregular basis. To the extent possible, all steps of the testing process must be controlled.

Evidence of Compliance:✓ Records reflecting that QC is run by the same personnel performing patient testing


amendments of 1988; final rule. Fed Register. 2003(Jan 24):7166 [42CFR493.1256(d)(8)]2) ibid, 2003(Jan 24):3708[42CFR493.1256(d)(7-8)

LSV.37094 QC Confirmation of Acceptability Phase II

The results of controls are reviewed for acceptability before reporting results.

NOTE: Control results must be reviewed before reporting patient/client results.

Evidence of Compliance:✓ Written policy stating that controls are reviewed and acceptable prior to reporting patient

results AND✓ Records of control result approval


amendments of 1988; final rule. Fed Register. 2003(Jan 24):7166 [42CFR493.1256(f)]2) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvement

amendments of 1988; final rule. Fed Register. 2003(Jan 24):3708 [42CFR493.1256(d)(6)]

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HEMATOLOGY SECTION

SPECIMEN COLLECTION AND HANDLING


● Sampling of hematology specimen collection and handling policies and procedures

● Sampling of patient CBC specimens (anticoagulant, labeling, storage)

● How do you know if the CBC specimen is clotted, lipemic, or hemolyzed?● How do you ensure the CBC sample is thoroughly mixed before analysis?● What is your course of action when you receive unacceptable hematology

specimens?

LSV.37096 Collection in Anticoagulant Phase II

All blood specimens collected in anticoagulant for hematology testing are mixedthoroughly immediately before analysis.

NOTE: Some rocking platforms may be adequate to maintain even cellular distribution ofpreviously well-mixed specimens, but are incapable of fully mixing a settled specimen. Forinstruments with automated samplers, the laboratory must ensure that the automated mixing timeis sufficient to homogeneously disperse the cells in a settled specimen.

Evidence of Compliance:✓ Records of evaluation of each specimen mixing method (eg, rotary mixer, rocker, automated

sampler, or manual inversions) for reproducibility of results, as applicable

REFERENCES1) Clinical and Laboratory Standards Institute. Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens;

Approved Standard; 6th ed. CLSI document GP42-A6. CLSI, Wayne, PA, 2008.2) Clinical and Laboratory Standards Institute. Collection of Diagnostic Venous Blood Specimens; 7th ed. CLSI standard GP41-ED7.

Clinical and Laboratory Standards Institute, Wayne, PA, 2017.

**REVISED** 09/17/2019LSV.37100 CBC Anticoagulant Phase II

Samples for complete blood counts and blood film morphology are collected in potassiumEDTA.

NOTE: Blood specimens for routine hematology tests (eg, CBC, leukocyte differential) mustbe collected in potassium EDTA to minimize changes in cell characteristics. Laboratories mustfollow manufacturer's recommendations for use of alternative anticoagulants.

REFERENCES1) Cohle SD, et al. Effects of storage of blood on stability of hematologic parameters. Am J Clin Pathol. 1981;76:67-79

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2) Savage RA. Pseudoleukocytosis due to EDTA-induced platelet clumping. Am J Clin Pathol. 1984;82:132-133

3) Rabinovitch A. Anticoagulants, platelets and instrument problems. Am J Clin Pathol. 1984;82:132

4) Clinical and Laboratory Standards Institute. Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens;Approved Standard; 6th ed. CLSI document GP42-A6. CLSI, Wayne, PA, 2008.

5) Clinical and Laboratory Standards Institute. Collection of Diagnostic Venous Blood Specimens; 7th ed. CLSI standard GP41-ED7.Clinical and Laboratory Standards Institute, Wayne, PA, 2017.

6) Broden PN. Anticoagulant and tube effect on selected blood cell parameters using Sysmex NE-series instruments. Sysmex J Intl.1992;2:112-119

7) Brunson D, et al. Comparing hematology anticoagulants: K2EDTA vs K3EDTA. Lab Hematol. 1995;1:112-119

8) Boos MS, et al. Temperature- and storage-dependent changes in hematologic variable and peripheral blood morphology. Am J ClinPathol. 1998;110:537

9) Wood BL, et al. Refrigerated storage improves the stability of the complete blood cell count and automated differential. Am J ClinPathol. 1999;112:687-695

LSV.37120 Capillary Tube Collection Criteria Phase II

Samples collected in capillary tubes for microhematocrits or capillary/dilution systems areobtained in duplicate whenever possible.

NOTE: Microspecimen containers such as those used for other capillary blood CBC parameterdeterminations need not be collected in duplicate. Because of the risk of injury, the use ofglass capillary tubes is discouraged; if glass capillary tubes are used, measures have beenimplemented to reduce risk or injury.

Evidence of Compliance:✓ Written procedure for collection in capillary tubes

REFERENCES1) Clinical and Laboratory Standards Institute. Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens;

Approved Standard. 6th ed. CLSI Document GP42-A6. Clinical and Laboratory Standards Institute, Wayne, PA; 2008.2) Occupational Safety and Health Administration. Toxic and hazardous substances. Bloodborne pathogens. Washington, DC: US

Government Printing Office, 1999(Jul 1): [29CFR1910.1030].

LSV.37140 Specimen Quality Assessment - CBC Phase II

CBC specimens are checked for clots (visual, applicator sticks, or automated analyzerhistogram inspection/flags) before reporting results.

NOTE: This may be done visually or with applicator sticks before testing. Additionally, microclotswill often present themselves histographically on automated and semi-automated particlecounters or by flagging, and the testing personnel must become familiar with such patterns.Finally, platelet clumps or fibrin may be microscopically detected if a blood film is prepared on thesame sample.

REFERENCES1) Clinical and Laboratory Standards Institute. Validation, Verification, and Quality Assurance of Automated Hematology Analyzers;

Approved Standard. 2nd ed. CLSI Document H26-A2. Clinical and Laboratory Standards Institute, Wayne, PA; 2010.

LSV.37160 Hemolyzed or Lipemic Specimens - CBC Phase II

CBC specimens are checked for significant in vitro hemolysis and possible interferinglipemia before reporting results.

NOTE: Specimens for complete blood counts must be checked for in vitro hemolysis that mayfalsely lower the erythrocyte count and the hematocrit, as well as falsely increase the plateletconcentration from erythrocyte stroma. Visibly red plasma in a tube of EDTA-anticoagulatedsettled or centrifuged blood should trigger an investigation of in vivo hemolysis (in which case theCBC data are valid) versus in vitro hemolysis (in which case some or all of the CBC data are notvalid and should not be reported). Lipemia may adversely affect the hemoglobin concentrationand the leukocyte count. This does not imply that every CBC specimen must be subjectedto centrifugation with visual inspection of the plasma supernatant, particularly if this wouldsignificantly impair the laboratory's turnaround time. An acceptable alternative for high volume

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laboratories with automated instrumentation is to examine the numeric data for anomalousresults (especially indices), as well as particle histogram inspection.

Evidence of Compliance:✓ Written procedure defining method for checking specimens for in vitro hemolysis and lipemia

REFERENCES1) Cantero M, et al. Interference from lipemia in cell count by hematology. Clin Chem. 1996;42:987-988

2) Clinical and Laboratory Standards Institute. Validation, Verification, and Quality Assurance of Automated Hematology Analyzers;


LSV.37190 Storage and Stability - Hematology Phase I

The laboratory has clearly defined sample storage conditions and stability for allhematology parameters.

NOTE: The laboratory should define sample storage conditions and stability for all hematologyparameters, as time- and temperature-dependent alterations can occur, creating spurious results.

Evidence of Compliance:✓ Written policy defining specimen stability and storage requirements

REFERENCES1) Boos MS, et al. Temperature- and storage-dependent changes in hematologic variable and peripheral blood morphology. Am J Clin

Pathol. 1998;110:5372) Gulati GL, et al. Changes in automated complete blood cell count and differential leukocyte count results induced by storage of blood

at room temperature. Arch Pathol Lab Med. 2002;126:336-3423) Clinical and Laboratory Standards Institute. Validation, Verification, and Quality Assurance of Automated Hematology Analyzers;


COMPLETE BLOOD COUNT (CBC) INSTRUMENTS

CBC INSTRUMENT CALIBRATION

Commercially available calibrator materials represent a convenient way to ensure that CBC instruments yieldaccurate results. Because of differences in technology, such calibrators are typically instrument-specific, and arecleared by the Food and Drug Administration for such use. These calibrators have more rigorous assignment oftarget values than ordinary commercial QC materials. Commercial control materials are not suitable for routineinstrument calibration.


● Sampling of CBC calibration policies or procedures● Sampling of CBC calibration records

● What is your course of action if the CBC instrument fails to pass all calibrationparameters?

● When was the last time you performed a calibration procedure and how did you verifythe calibration?

LSV.37200 Precalibrated Instrument Verification Phase II

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If precalibrated instruments are used, the manufacturer's calibrations are verified withappropriate control materials for the system.

NOTE: This requirement does not apply to CBC instruments that can be calibrated by thelaboratory.

Evidence of Compliance:✓ Records of calibration verification following manufacturer's instructions

REFERENCES1) van Assendelft OW, Buursma A. Reference method for the measurement of hemoglobin. Lab Hematol. 1995;1:154-155

2) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvementamendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1255]

COMMERCIAL CALIBRATORS

Commercially available calibrator materials represent a convenient way to ensure that CBC instruments yieldaccurate results. Because of differences in technology, such calibrators are typically instrument-specific, and arecleared by the Food and Drug Administration for such use. These calibrators have more rigorous assignmentof target values than ordinary commercial QC materials, and the latter must not be used for routine instrumentcalibration.

LSV.37340 Calibration Phase II

There is a written procedure defining the criteria and specific steps for the periodiccalibration of the analyzer with stabilized materials whose target values have beencertified by the manufacturer using primary reference procedures.

REFERENCES1) Gilmer PR, Williams LJ. The status of methods of calibration in hematology. Am J Clin Pathol. 1980;74:600-605

2) Lewis SM, et al. Current concepts in haematology 3: blood count calibration. J Clin Pathol. 1991;144:881-884

3) Clinical and Laboratory Standards Institute (CLSI). Validation, Verification, and Quality Assurance of Automated HematologyAnalyzers; Approved Standard—Second Edition. CLSI document H26-A2 (ISBN 1-56238-728-6). Clinical and Laboratory StandardsInstitute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898 USA, 2010.

4) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvementamendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1255]

**REVISED** 09/17/2019LSV.37370 Calibration Verification Criteria Phase II

Criteria are established for calibration verification.

NOTE: The laboratory must have a written procedure for calibration verification. Criteria forcalibration verification include:

1. At complete changes of reagents (ie, change in type of reagent from same vendor, orchange to a different vendor)

2. When indicated by quality control data3. After major maintenance or service4. When recommended by the manufacturer5. At least every six months

For automated CBC cell counting instruments, requirements for calibration verification may beconsidered met if the laboratory follows the manufacturer's instructions for instrument operationand tests two levels of control materials each day of testing. The control results must meet thelaboratory's criteria for acceptability. Linearity studies are not required.

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Evidence of Compliance:✓ Written procedure defining the method, frequency and limits of acceptability of calibration

verification for each instrument/test system AND✓ Records of calibration verification at defined frequency


amendments of 1988; final rule. Fed Register. 2003(Jan 24):7165 [42CFR493. 1255]

LSV.37380 Recalibration Phase II

The laboratory's procedure for recalibration of a parameter(s) requires analysis ofstabilized whole blood or other commercial preparations, the parameters of which havebeen certified by the manufacturer.

Evidence of Compliance:✓ Written procedure for recalibration

CBC INSTRUMENT QUALITY CONTROL

Longitudinal process quality control (QC) procedures for individual instruments may include:

1. Use of preserved or stabilized whole blood controls2. "Moving average" monitoring3. Retained patient specimens, or4. Some combination of the above

At least two different controls must be assayed and evaluated every 24 hours. For each QC procedureemployed, the laboratory must have appropriate QC ranges. For example, expected recovery ranges forcommercial control materials are NOT the same as between-run SD ranges, and are probably too wide for dailyQC of a single instrument. The laboratory should calculate its own imprecision statistics for each instrument.


● Sampling of QC policies and procedures● Sampling of QC records from the previous two-year period● Sampling of CBC error detection policies and procedures


● How does your laboratory establish or verify acceptable QC ranges?● How do you ensure results from CBC specimens with cold agglutinins, nucleated

RBCs and lipemia are reported accurately?


● Select a spurious result example and follow the process used to ensure the correctresults are reported

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STABILIZED CONTROLS

LSV.37460 QC - Stabilized Controls Phase II

Two different stabilized control specimens are analyzed and results recorded during each24-hours of analyzer use.

NOTE: Stabilized control materials must be at two different analytic levels (ie, "normal" and"high"). Three levels of control is a conceptual carryover from clinical chemistry, and does notapply to hematology particle counting. Dilute, "low-level" (eg, leukopenic and thrombocytopenic)"oncology" controls are less informative indicators of calibration status, and are neither requirednor recommended. For example, a 10% calibration bias will be numerically most apparent in ahigh-level control, less apparent in a normal-level control, and perhaps inapparent in a low-levelcontrol; it would be quite extraordinary for a low-level control to indicate a calibration problem thatis not revealed by the other controls. There should be some relationship between the frequencyof control runs and the numbers of patient specimens processed. If the frequency of commercialcontrol use is less than two control specimens per 24 hours, one or more of the additionalapproaches to QC must be employed to produce a total of at least two different data points per24 hours.

REFERENCES1) Lott JA, et al. Synthetic materials for platelet quality control. Am J Med Technol. 1983;49:4348

2) Yacko M, et al. Multiple methods for platelet enumeration. Observation of a newly introduced bias. Am J Clin Pathol.1987;87:109-112

3) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvementamendments of 1988; final rule. Fed Register. 2003(Jan 24):7168 42CFR493. 1256(d)]

4) Dotson MA. Methods to monitor and control systematic error. In: clinical hematology: principles, procedures, correlations, 2nd edition.Stiene-Martin EA, et al, eds. Philadelphia, PA: Lippincott, 1998:579-590

5) Fink NE, et al. Evaluation and additional recommendations for preparing a whole blood control material. Rev Saude Publica.1998;32:107-111

6) Springer W, et al. Evaluation of a new reagent for preserving fresh blood samples and its potential usefulness for internal qualitycontrol of multichannel hematology analyzers. Am J Clin Pathol. 1999;111:387-396

LSV.37515 Precision Statistics Phase I

The laboratory has an action protocol when data from precision statistics changesignificantly from previous data.

NOTE: As an example, if the laboratory's normal-level commercial control usually yields amonthly CV of 2% for WBC, but the most recent month shows a 4% CV, then something hascaused increased imprecision, and investigation with records is required. Similarly, if the monthlySD for MCV by moving averages is typically around 1.8 fL, but now is at 3.1 fL, the laboratorymust find a cause for this shift and take action. If commercially sponsored interlaboratory QCdata for the same control lot and instrument model show SD/CV values outside those of the peergroup, an explanation is required.

Evidence of Compliance:✓ Written procedure for investigation and corrective action if a significant change in precision

statistics occurs AND✓ Records of investigation and corrective actions taken

MOVING AVERAGES

The technique of weighted moving averages (derived from multiple batch analysis of patient samples) isacceptably sensitive to drifts or shifts in analyzer calibration if a supplemental QC routine (stabilized control

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material or retained patient specimens) is employed. The latter is needed to detect random error and to avoidbias due to masking of drift by characteristics of the subpopulations within each individual batch.

Laboratories analyzing fewer than 100 CBC specimens daily (long term average) should not use movingaverages as the primary method for process control, as this would not generate sufficient data within a day to beof value.

Depending on the particular instrument, there may be "on-board" moving average analyses for RBC indicesonly. In such cases, additional QC techniques are required for WBC, PLT and WBC differential parameters.However, some laboratories have found the mathematical logic of moving averages, modified average ofnormals, etc., applicable to other CBC parameters, and some instruments have these capabilities built into theirsoftware. Or, such calculations may be performed with an associated computer.

LSV.37540 QC - Moving Averages Phase II

Control limits for moving averages are appropriately sensitive.

NOTE: Control limits for moving averages must be appropriately sensitive such that significantcalibration alterations are always detected. Recalibration is not required for minor calibrationvariations of no clinical consequence. In other words, there should be a high probability for errordetection and a low probability for false rejection.

Evidence of Compliance:✓ Written procedure defining the:

● method used to establish the moving average AND● frequency of calculation (batch size) AND

✓ Definition of the basis for selection of upper and lower limits

REFERENCES1) Bull BS, et al. A study of various estimators for the derivation of quality control procedures from patient erythrocyte indices. Am J Clin

Pathol. 1974;61:473-4812) Talamo TS, et al. Microcomputer assisted hematology quality control using a modified average of normals program. Am J Clin

Pathol. 1981; 76:707-7123) Bull BS, Korpman RA. Autocalibration of hematology analyzers. J Clin Lab Automation. 1983;3:111-116

4) Cembrowski GS, Westgard JO. Quality control of multichannel hematology analyzers: evaluation of Bull's algorithm. Am J ClinPathol. 1985;83:337-345

5) Bull BS, Hay KL. Are red blood cells indexes international? Arch Pathol Lab Med. 1985;109:604-606

6) Levy WC, et al. Preserved blood versus patient data for quality control - Bull's algorithm revisited. Am J Clin Pathol. 1986;85:719-721

7) Levy WC, et al. The incorporation of red blood cell index mean data into quality control programs. Am J Clin Pathol. 1986;86:193-199

8) Lunetzky ES, Cembrowski GS. Performance characteristics of Bull's multirule algorithm for the quality control of multichannelhematology analyzers. Am J Clin Pathol. 1987;88:634-638

9) Clinical and Laboratory Standards Institute (CLSI). Validation, Verification, and Quality Assurance of Automated HematologyAnalyzers; Approved Standard—Second Edition. CLSI document H26-A2 (ISBN 1-56238-728-6). Clinical and Laboratory StandardsInstitute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898 USA, 2010.

LSV.37600 QC Procedure Phase II

If a "moving averages" system is combined with another control system, (eg, commercialcontrols or retained patient specimens) the process is well defined and appropriatelysensitive to drift in analyzer calibration.

Evidence of Compliance:✓ Written QC procedure defining criteria for the use of a moving average system in conjunction

with another QC system

REFERENCES1) Cembrowski GS, Clarke G. Quality control of automated cell counters. Clin Lab Med. 2015;35:59-71.

2) Verbrugge SE, Huisman A. Verification and standardization of blood cell counters for routine clinical laboratory tests. Clin Lab Med.2015;35:183-96.

3) Vis JY, Huisman A. Verification and quality control of routine hematology analyzers. Int J Hematol. 2016;38(suppl 1):100-9.

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RETAINED PATIENT SPECIMENS

Use of retained patient specimens alone is inadequate for routine QC of the primary CBC instrument, andmust be considered as a supplemental procedure, in combination with another QC system. Retained patientspecimens, while conveniently available, present some difficulties in mathematically defining "agreement"between CBC results separated in time, as these are not stabilized samples. This is in contrast to commercialcontrol materials that have been treated to reduce time-dependent degradation.

LSV.37606 QC - Retained Patient Specimens Phase I

When the laboratory uses retained patient samples, statistically defined limits are used todetermine agreement of sequential assays of a given sample.

NOTE: Allowance should be made for time-dependent alterations in data from such labilesamples.

Evidence of Compliance:✓ Written QC procedure defining the control limits for repeat analysis of retained patient

specimens AND✓ QC records showing the use of the defined control limits

LSV.37612 QC - CBC Defined Range Phase I

There is a defined range of CBC values for which these limits are applicable.

NOTE: Because imprecision (standard deviation, coefficient of variation) is dependent upon thehematologic target value, the laboratory should restrict the use of these limits to appropriateranges of CBC values.

Evidence of Compliance:✓ Written QC procedure for retained patient specimen controls defining the CBC target values

for which the defined control limits are applicable

ERROR DETECTION AND VERIFICATION

**REVISED** 09/17/2019LSV.37650 Sampling Mode Comparison Phase I

There are records that at least annually compare all results obtained for patientspecimens analyzed in the multiple sampling modes of the CBC analyzer (eg, "primary"and "secondary" modes) to ensure that they are in agreement.

NOTE: Different modes may involve dilution or a different sample path before analysis. Whensamples are analyzed in more than one mode, it is important to ensure that all modes functionproperly. Re-analysis of a previously analyzed sample must be performed in the alternatemode(s), and results must agree with the initial mode within the tolerance limits established foragreement by the hematology laboratory's quality control program, and any recommendations bythe instrument manufacturer. Mode to mode correlation is not necessary for those analyzers thatuse the same pathway and have no dilution involved.

Evidence of Compliance:✓ Written procedure for sampling mode comparison with defined criteria for agreement AND

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✓ Records of sampling mode comparison studies

**REVISED** 06/04/2020LSV.37660 Detection/Correction Procedure - WBC Phase II

There is a written procedure for detecting and correcting automated WBC counts for thepresence of nucleated red cells or megakaryocytes.

NOTE: The effect of nucleated erythrocytes and blood megakaryocytes on the apparent WBCcount varies with the system used for analysis. Each laboratory must evaluate its system(s) anddevelop appropriate detection and correction procedures. This is important to prevent reporting afalsely high WBC concentration. With some automated CBC instruments, nucleated erythrocytesor megakaryocytes may present themselves histographically or cytographically, and this canserve as an indicator for careful inspection of a stained blood film. The laboratory must establishif its particular instrument(s) includes some or all nucleated non-leukocytes in its apparent WBC"count".

Evidence of Compliance:✓ Records showing actions taken to verify WBC concentration prior to reporting

REFERENCES1) Zandecki M, Genevieve F, Gerard J, Gordon A. Spurious counts and spurious results on haematology analyzers: a review. Part II:

white blood cell, red blood cells, haemaglobin, red cell indices and reticulocytes. Int J Lab Hematol. 2007;29(1):21-41.2) Barnes PW, McFadden SL, Machin SJ, Simson E. The international consensus group for hematology review: suggested criteria for

action following automated CBC and WBC differential analysis. Lab Hematol. 2005;11(2):83-90.

**REVISED** 06/04/2020LSV.37680 Spurious CBC Results Phase II

There is a written procedure to detect spurious CBC instrument results that maybe clinically significant (eg, pseudomacrocytosis from rouleaux or agglutinates;pseudoleukocytosis with erroneous hemoglobin, falsely low erythrocyte count andhematocrit; hyperlipemias) prior to reporting.

NOTE: Analytic sources of error with automated instruments depend on the type of instrumentand reagents used by the laboratory.

Evidence of Compliance:✓ Written procedure to detect spurious CBC results AND✓ Record of action taken when spurious CBC instrument results are detected


white blood cell, red blood cells, haemaglobin, red cell indices and reticulocytes. Int J Lab Hematol. 2007;29(1):21-41.2) Zandecki M, Genevieve F, Gerard J, Gordon A. Spurious counts and spurious results on haematology analyzers: a review. Part I:

platelets. Int J Lab Hematol. 2007;29(1):4-20.3) Barnes PW, McFadden SL, Machin SJ, Simson E. The international consensus group for hematology review: suggested criteria for

action following automated CBC and WBC differential analysis. Lab Hematol. 2005;11(2):83-90.4) Lee EJ, Lee AI. Thrombocytopenia. Prim Care. 2016;43:543-67.

**REVISED** 06/04/2020LSV.37700 Red Cell Indices Phase I

Red cell indices (MCV, MCH, MCHC) are monitored routinely to detect random errors.

NOTE: Patient sample red cell indices (MCV, MCH, MCHC) must be monitored routinelyto detect random errors, instrument malfunction, or spurious results. On many automatedinstruments, the MCHC is the most useful parameter to ensure accuracy of the red cellparameters in individual patient samples. Since MCHC varies over a narrow range, an abnormalMCHC will often flag potentially spurious red cell parameters. Truly elevated MCHCs may beseen with spherocytosis, while decreased MCHCs can accompany a low MCV in severe irondeficiency anemia. If such RBC abnormalities are not present on the blood film, one or more

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of the measured RBC parameters is likely erroneous. Incorrect data may be due to instrumentmalfunction or to problems with the blood sample itself. MCV and MCH are fairly constant foreach patient, and monitoring these indices in a delta check error detection program may providerapid patient-based detection of instrument malfunction or specimen misidentification.

Evidence of Compliance:✓ Written procedure defining the criteria used to monitor the red cell indices to detect random

errors AND✓ Record of action taken when RBC indices are in question, including the reporting of results


white blood cell, red blood cells, haemaglobin, red cell indices and reticulocytes. Int J Lab Hematol. 2007;29(1):21-41.2) Barnes PW, et al. The international consensus group for hematology review: suggested criteria for action following automated CBC

and WBC differential analysis. Lab Hematol. 2005;11(2):83-90.3) Cembrowski GS, Clarke G. Quality control of automated cell counters. Clin Lab Med. 2015;35:59-71.

4) Verbrugge SE, Huisman A. Verification and standardization of blood cell counters for routine clinical laboratory tests. Clin Lab Med.2015;35:183-96.

5) Vis JY, Huisman A. Verification and quality control of routine hematology analyzers. Int J Hematol. 2016;38(suppl 1):100-9.

LSV.37720 Reportable Range Phase II

Upper and lower limits of all reportable parameters on the CBC instrument are defined,and results that fall outside these limits are reported properly.

NOTE: The laboratory must initially establish or verify the reportable range for each parameterof its automated or semi-automated CBC instrument. In particular, the laboratory must havedata on its instrument's accuracy with thrombocytopenic and leukopenic samples. Plateletconcentrations below the established lower limits must be reanalyzed by another method (eg,manual hemocytometry, or semiquantitative blood film estimates, or fluorescence flow cytometryusing specific platelet monoclonal antibodies). Particle (WBC, RBC, PLT) concentrations abovethe established upper limits must, as clinically needed, be reanalyzed by doing the minimumdilution necessary to bring the counts into the instrument's analytic range. When clinicallyappropriate, apparent analyte concentrations that are lower or higher than the reportable rangemay be reported as "less than" the lower limit or "greater than" the higher limit.

Evidence of Compliance:✓ Written policy defining the upper and lower instrument reporting limits AND✓ Record of action taken when limits are exceeded, including the reporting of results


amendments of 1988; final rule. Fed Register. 2003(Jan 24):7164 [42CFR493.1253]2) Hanseler E, et al. Estimation of the lower limits of manual and automated platelet counting. Am J Clin Pathol. 1996;105:782-787

3) Ault KA. Implementation of the immunological platelet count on a hematology analyzer - the Abbott Cell-Dyn 4000. Lab Hematol.1997;3:125-128

**REVISED** 09/17/2019LSV.37740 Platelet Abnormalities Phase II

There is an adequate system (such as microscopic correlation with the blood film) toprevent reporting of spurious thrombocytopenia when platelet clumps, giant platelets, orplatelet satellitism are present.

NOTE: When platelet satellitosis (satellitism), significant numbers of giant platelets and/or plateletclumps are suspected/detected by cyto/histographic abnormalities or instrument rejection ofa platelet result, the platelet concentration must be independently verified. Correlation with awell-prepared blood film must be made. If platelets are clumped after collection in an EDTA-anticoagulated tube that was well-mixed at the time of collection, this may represent in vitroEDTA-induced changes; platelets must be quantified from blood collected directly into a countingdiluent, by use of a different anticoagulant per manufacturer's recommendations, or by estimationfrom a non-anticoagulated blood film.

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Evidence of Compliance:✓ Written procedure defining the methods used to detect spurious thrombocytopenia or platelet

abnormalities and to correct results AND✓ Record showing actions taken to verify platelet concentration prior to reporting

REFERENCES1) Hyun BH, et al. Platelet satellitosis. Chicago, IL: American Society of Clinical Pathologists Check Sample H78, 1976

2) Veenhoven WA, et al. Pseudothrombocytopenia due to agglutinins. Am J Clin Pathol. 1979;72:1005-1008

3) Gloster ES, et al. Spurious platelet counts associated with bacteremia. Am J Hematol. 1985;18:329-332

4) Cunningham VL, Brandt JT. Spurious thrombocytopenia due to EDTA-independent cold-reactive agglutinins. Am J Clin Pathol.1992;97:359-362

5) Hanseler E, et al. Estimation of the lower limits of manual and automated platelet counting. Am J Clin Pathol. 1996;105:782-787

6) Bridgen ML, Dalal BU. Cell counter-related abnormalities. Lab Med. 1999;30:325-334

7) Kunicka JE, et al. Improved platelet counting using two-dimensional laser light scatter. Am J Clin Pathol. 2000;114;114:283-289

LSV.37760 Spuriously High WBC Concentration Phase II

If significant numbers of unlysed RBC, giant platelets and/or platelet clumps aresuspected/detected, the WBC concentration is rechecked by another method or bloodfilms are examined to prevent reporting spuriously high WBC concentrations.

NOTE: When unlysed RBC, PLT satellitosis, significant numbers of giant PLT and/or PLT clumpsare suspected/detected by histographic abnormalities or instrument rejection of the PLT result,the WBC count must be verified manually, by automated counting after collection into a differentanticoagulant, by automated counting in a lyse-resistant mode, or by semiquantitative blood filmevaluation to prevent reporting spuriously high WBC concentrations.

Evidence of Compliance:✓ Written procedure defining the criteria for the detection and correction of falsely elevated

WBC counts AND✓ Record showing actions taken to verify WBC concentration prior to reporting


white blood cell, red blood cells, haemaglobin, red cell indices and reticulocytes. Int J Lab Hematol. 2007;29(1):21-41.2) Zandecki M, Genevieve F, Gerard J, Gordon A. Spurious counts and spurious results on haematology analyzers: a review. Part I:

platelets. Int J Lab Hematol. 2007;29(1):4-20.

LSV.37780 Platelet Count Verification Phase II

If significant numbers of microcytic erythrocytes and/or small cell fragments are detected/suspected, the platelet count is determined or verified using an alternate method.

NOTE: When a significant number of interfering particles are identified at the upper or lower PLTcounting threshold (by inspection of the PLT histogram or instrument flag), the PLT concentrationmust be determined or verified by an alternate method. Such methods could include alternateinstrumentation, hemocytometry, or blood film estimate, depending upon the PLT concentrationand the degree of clinical accuracy required.

Evidence of Compliance:✓ Written procedure defining the criteria for detection of microcytic RBC and cell fragments that

interfere with platelet counts AND✓ Records showing action taken to verify platelet concentration prior to reporting

REFERENCES1) Morton BD, et al. Pappenheimer bodies: an additional cause for a spurious platelet count. Am J Clin Pathol. 1980;74:310-311

2) Akware AM, et al. Spuriously elevated platelet counts due to microspherocytosis. Am J Clin Pathol. 1982;77:220-221

3) Gloster ES, et al. Spurious elevated platelet counts associated with bacteremia. Am J Hematol. 1985;18:329-332

4) Bridgen ML, Dalal BI. Cell counter-related abnormalities. Lab Med. 1999;30:325-334

5) Li S, Salhany KE. Spurious elevation of automated platelet counts in secondary acute monocytic leukemia associated with tumorlysis syndrome. Arch Pathol Lab Med. 1999;123:1111-1114

6) Kunicka JE, et al. Improved platelet counting using two-dimensional laser light scatter. Am J Clin Pathol. 2000;114;114:283-289

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MANUAL HEMATOCRIT


● Hematocrit procedure● Sampling of annual centrifuge speed checks● Sampling of timer checks

LSV.38240 Microhematocrit Centrifuge Phase I

The speed of the microhematocrit centrifuge is checked at least annually.

NOTE: Relative centrifugal field (RCF) must be sufficient to achieve maximum packing of cells.The centrifuge must be capable of sustaining an RCF of 10,000 to 15,000 at the periphery for fiveminutes.

If the centrifuge speed cannot be checked by the user, the laboratory must annually comparecentrifuge test results against another centrifuge with known speed and constant packing time. Ifthe laboratory does not have such an instrument, another laboratory or an outside vendor may beused for this comparison.

Evidence of Compliance:✓ Written policy defining criteria for verification of centrifuge operating speeds AND✓ Records of microhematocrit centrifuge speed checks

REFERENCES1) Clinical and Laboratory Standards Institute. Procedure for Determining Packed Cell Volume by the Microhematocrit Method;

Approved Standard; 3rd ed. CLSI document H07-A3. CLSI, Wayne, PA, 2000.

LSV.38260 Mechanical Timer Phase II

If a mechanical timer is used, its accuracy is checked at least annually.

NOTE: Not applicable to electronic timers.

Evidence of Compliance:✓ Records of mechanical timer checks

LSV.38280 Constant Packing Time Phase II

The constant packing time (minimum spin to reach maximum packing of cells) isestablished before initial use and reassessed when there has been a change in either thespeed or time.

Evidence of Compliance:✓ Written policy defining criteria for establishing/reassessing constant packing time AND✓ Records of initial and reassessment studies as appropriate

REFERENCES1) Clinical and Laboratory Standards Institute. Procedure for Determining Packed Cell Volume by the Microhematocrit Method;

Approved Standard; 3rd ed. CLSI document H07-A3. CLSI, Wayne, PA, 2000.

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MANUAL BLOOD COUNT

NOTE: Counting chamber RBC counts are not recommended because of the level of imprecision and inability toverify results against a stained blood film.


● Manual cell counts procedure● Sampling of QC logs

● How do you correlate counting chamber platelet counts?● How do you ensure that your diluting fluids are free from contamination?

LSV.38380 Manual Counts - PLT/WBC Phase II

If WBC or PLT counts are performed manually by pipette dilution and chamber count,each sample is counted in duplicate, plating both chambers of a standard hemocytometer.

NOTE: Performance of the counts in duplicate is required for all hemocytometers, whether glassor disposable.

Evidence of Compliance:✓ Written procedure for manual PLT/WBC count requiring duplicate counts and defined limits of

agreement AND✓ Records or worksheets reflecting duplicate counts and corrective action when limits of

agreement are exceeded


amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1269(a)(2)]

LSV.38400 Manual Counts - PLT/WBC Phase I

When there is leukopenia or thrombocytopenia, the manual hemocytometer procedurerequires a technique to offset the increased error associated with counting smallernumbers of cells in the hemocytometer.

NOTE: The written procedure must specify an increased number of cells counted (eg, increasednumber of hemocytometer squares enumerated or a lesser specimen dilution) when there isleukopenia or thrombocytopenia, in order to avoid increasing the imprecision of particle counting,which is governed by binomial distributions and Poisson statistics.

Evidence of Compliance:✓ Written procedure for contamination checks on dilution fluids and reagents AND✓ Records of contamination checks on dilution fluids/reagents

REFERENCES1) Barnett RN. Clinical laboratory statistics, 2nd ed. Boston, MA: Little, Brown, 1979:30-33, 101-103

2) Miale JB. Laboratory medicine hematology, 6th ed. St Louis, MO: CV Mosby, 1982:373-374

3) Savage RA. Evaluate your practice for platelet counts. Northfield, IL: College of American Pathologists Summing Up, Fall 1987

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LSV.38420 Contamination Checks Phase II

There is a written procedure for assuring that dilution fluids and reagents are free ofcontaminants that may spuriously change the true cell counts.

NOTE: Suggested checks include pH, osmolality and background counts.

Evidence of Compliance:✓ Written procedure for contamination checks on dilution fluids and reagents AND✓ Records of contamination checks on dilution fluids/reagents

LSV.38440 Cell Count Controls Phase II

At least one cell count control specimen is analyzed in duplicate, or a procedural controlemployed for each eight hours of patient testing.

NOTE: For WBC and PLT, this requirement can be met with assayed liquid control material,a previously assayed patient sample, or comparison with a visual blood film concentrationestimate. Visual estimates are not appropriate for RBC hemocytometry. This requirement doesnot apply to body fluid samples. Liquid controls performed in a hemocytometer must be run induplicate.

Evidence of Compliance:✓ Written policy defining quality control requirements for manual cell counts AND✓ Records of cell count or procedural controls at defined frequency



LSV.38460 PLT Estimate Phase I

For platelet hemocytometry, the manual count is correlated with a platelet estimate from aproperly prepared blood film.

Evidence of Compliance:✓ Records of slide review/correlation

REFERENCES1) Barnes PW, et al. The international consensus group for hematology review: suggested criteria for action following automated CBC

and WBC differential analysis. Lab Hematol. 2005;11(2):83-90.2) Lee EJ, Lee AI. Thrombocytopenia. Prim Care. 2016;43:543-67.

AUTOMATED DIFFERENTIALS


● Automated differential procedure● Sampling of QC records

● What action would you take when there is a flagged result?

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LSV.38470 Limits of Agreement - WBC Phase II

Acceptable limits for quality control procedures for WBC subclasses using manuallycounted blood films or commercial controls are defined.

NOTE: For automated analyzers, at least two approaches are reasonable: 1) comparison ofinstrument differentials on fresh blood samples with a conventional manual differential count,and/or 2) use of commercially available stabilized leukocytes and/or particle surrogate controlmaterial. The automated instrument and reference determinations should be treated as replicatemanual differentials and evaluated using the ± 2 or 3 SD agreement limits of Rümke. For patternrecognition microscopy systems, QC can be done by periodic processing of prepared controlslides and maintenance/analysis of Levey-Jennings charts.

For commercial controls, mixed leukocyte subclasses (eg, "mononuclear" or "large unclassifiedcells") or "remainder" fractions do not need to be assessed with QC procedures. The commercialmaterial must contain surrogate particles to measure total neutrophils, total granulocytes, totallymphoid cells, monocytes, eosinophils, and basophils, if these subtypes are enumerated by theinstrument and reported by the laboratory. If discrete populations of abnormal cells are identifiedand enumerated by the instrument (eg, nucleated RBC, blasts), then the QC material mustcontain surrogate particles to evaluate accuracy.

Evidence of Compliance:✓ Written procedure defining quality control requirements for automated WBC differentials

REFERENCES1) Rümke CL. The statistically expected variability in differential leukocyte counts. In: Differential leukocyte counting, CAP conference/

Aspen. Northfield, IL: CAP, 1977:39-452) Kalish RJ, Becker K. Evaluation of the Coulter S-Plus V three-part differential in a community hospital, including criteria for its use.

Am J Clin Pathol. 1986;86:751-7553) Etzell, JE. For WBC differentials reporting absolute numbers. CAP Today, March 2010

4) Richardson-Jones A, Twedt D, Hellman R. Absolute versus proportional differential leukocyte counts. Clin Lab. Haem. 1995:17,115-123

5) Ross DW, Bentley SA. Evaluation of an automated hematology system (Technicon H1). Arch Pathol Lab Med. 1986;110:803-808

6) Clinical and Laboratory Standards Institute (CLSI). Reference Leukocyte (WBC) Differential Count (Proportional) and Evaluation ofInstrumental Methods; Approved Standard—Second Edition. CLSI document H20-A2 (ISBN 1-56238-628-X). Clinical and LaboratoryStandards Institute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898 USA, 2007

7) Miers MK, et al. White blood cell differentials as performed by the Technicon H-1; evaluation and implementation in a tertiary carehospital. Lab Med. 1991;22:99-106

8) Hallawell R, et al. An evaluation of the Sysmex NE-8000 hematology analyzer. Am J Clin Pathol. 1991;96:594-601

9) Cornbleet PJ, et al. Evaluation of the Cell-dyn 3000 differential. Am J Clin Pathol. 1992;98:603-614

10) Krause JR. The automated white blood cell differential. A current perspective. Hematol Oncol Clin North Am. 1994;8:605-16

11) Goyzueta FG, et al. Automated differential white blood cell counts in the young pediatric population. Lab Med. 1996;27:4852

12) Gulati GL, et al. Suspect flags and regional flags on the Coulter-STKS. An assessment. Lab Med. 1999;30:675-680

13) Grimaldi E, Scopacasa F. Evaluation of the Abbott CELL-DYN 4000 hematology analyzer. Am J Clin Pathol. 2000;113:497-505

LSV.38490 WBC Differential Verification Phase II

The laboratory has established criteria for checking and reviewing leukocyte differentialcounter data, histograms, and/or blood smears for clinically important results flagged bythe automated differential counter.

NOTE: Clinically important results include pathologic quantities of normal cell types andabnormal cells. Flagging mechanisms include those within the particular instrument, inspection ofhistographic/cytographic displays, laboratory criteria based on local experience, and awarenessof published evaluations.

Evidence of Compliance:✓ Written procedure defining criteria for review and evaluation of automated differential results

prior to reporting AND✓ Records of verification of flagged values

REFERENCES1) Rümke CL. The statistically expected variability in differential leukocyte counts. In: Differential leukocyte counting, CAP conference/

Aspen. Northfield, IL: CAP, 1977:39-452) Payne BA, Pierre RV. Using the three-part differential: part II. Implementation of the system. Lab Med. 1986;17:517-522

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3) Kalish RJ, Becker K. Evaluation of the Coulter S-Plus V three-part differential in a community hospital, including criteria for its use.Am J Clin Pathol. 1986;86:751-755

4) Ross DW, Bentley SA. Evaluation of an automated hematology system (Technicon H-1). Arch Pathol Lab Med. 1986;110:803-808

5) Clinical and Laboratory Standards Institute (CLSI). Reference Leukocyte (WBC) Differential Count (Proportional) and Evaluation ofInstrumental Methods; Approved Standard—Second Edition. CLSI document H20-A2 (ISBN 1-56238-628-X). Clinical and LaboratoryStandards Institute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898 USA, 2007

6) Miers MK, et al. White blood cell differentials as performed by the Technicon H-1; evaluation and implementation in a tertiary carehospital. Lab Med. 1991;22:99-106

7) Hallawell R, et al. An evaluation of the Sysmex NE-8000 hematology analyzer. Am J Clin Pathol. 1991;96:594-601

8) Cornbleet PJ, et al. Evaluation of the Cell-dyn 3000 differential. Am J Clin Pathol. 1992;98:603-614

9) Krause JR. The automated white blood cell differential. A current perspective. Hematol Oncol Clin North Am. 1994;8:605-16

10) Goyzueta FG, et al. Automated differential white blood cell counts in the young pediatric population. Lab Med. 1996;27:48-52

11) Gulati GL, et al. Suspect flags and regional flags on the Coulter-STKS. An assessment. Lab Med. 1999;30:675-680

MANUAL DIFFERENTIALS

This section applies to all manually interpreted differentials, including those performed using automated imageanalysis systems requiring manual verification or interpretation of cell classification or other morphologicfindings.


● Manual differential policies and procedures

● Sampling of patient peripheral blood smears (uniquely identified, properly stained,free of precipitate, good cell distribution)

● File of unusual slides

● How do you ensure consistency among personnel performing blood cell microscopy?● What criteria are used for referring a blood film for review by a pathologist,

supervisor, or technologist with expertise in hematomorphology?

LSV.38500 Blood Film Quality Phase I

The quality of blood films is satisfactory (properly stained, free of precipitate, good celldistribution).

REFERENCES1) Wenk RE. Comparison of five methods for preparing blood smears. Am J Med Technol. 1976;42:71-78

2) College of American Pathologists. Differential leukocyte counting. CAP conference/aspen. Northfield, IL: CAP, 1977

3) Stiene-Martihn EA. Causes for poor leukocyte distribution in manual spreader-slide blood films. Am J Med Technol. 1980;46:624-632

4) Lewis SM. Blood film evaluations as a quality control activity. Clin Lab Haematol. 1990;12:119-127

5) Turgeon ML. Clinical hematology, theories and procedures, 2nd ed. Boston, MA: Little, Brown, 1993;16-25

6) Dacie JV, Lewis SM. Practical hematology, 8th ed. New York, NY: Churchill Livingstone, 1995;83-89

LSV.38525 Stain Reactivity Phase II

All stains are checked for intended reactivity each day of use.

Evidence of Compliance:✓ Written procedures for stain QC AND✓ Records of stain QC at defined frequency

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amendments of 1988; final rule. Fed Register. 2003(Jan 24):7166 [42CFR493.1256(e)(2)]

**REVISED** 09/17/2019LSV.38540 Morphologic Observation Evaluation - CBC Phase II

The laboratory evaluates consistency of morphologic observation among personnelperforming blood cell microscopy at least annually.

NOTE: The laboratory must ensure the identification and morphology of blood cells is reportedconsistently amongst all personnel performing the microscopic analysis.

Suggested methods to accomplish this include:

1. Circulation of a pre-graded set of blood films with defined leukocyte differentialdistributions, and RBC and platelet morphology.

2. Multi-headed microscopy3. Use of blood or marrow photomicrographs with referee and consensus identifications

(eg, former CAP surveys photomicrographs)4. Use of digital images

In the case of comparative blood film WBC differentials, the method of Rümke is recommendedto define statistical agreement between observers.

Acceptability criteria for agreement must be determined by the laboratory director or designee.The laboratory must maintain records of performance and record corrective actions taken forpersonnel demonstrating significant discrepancies from the group consensus.

Evidence of Compliance:✓ Written procedure defining the method and criteria used for evaluation of consistency AND✓ Records of evaluation

REFERENCES1) Rümke CL. The statistically expected variability in differential leukocyte counts, In: Differential leukocyte counting, CAP conference/

Aspen. Northfield, IL: CAP, 1977:39-452) Wood B, et al. Teaching the clinical interpretation of peripheral blood smears to second-year medical school class using the

peripheral blood-tutor computer program. Am J Clin Pathol. 1998;109:514-5203) College of American Pathologists. Surveys hematology glossary. Northfield, IL: CAP, 1999:1-26

4) Brigden ML, Dalal BI. Morphologic abnormalities, pseudosyndromes, and spurious test results. Lab Med. 1999;30:397-405

5) Haun DE, et al. A better way to assess WBC differential counting skills. Lab Med. 2000;31:329-333

6) College of American Pathologists Hematology and Clinical Microscopy Resource Committee. Hematology Benchtop ReferenceGuide: An Illustrated Guide for Cell Morphology. Northfield, IL: College of American Pathologists, 2012.

7) Glassey E, ed. Color Atlas of Hematology: An Illustrated Field Guide Based on Proficiency Testing. 2nd Ed. College of AmericanPathologists. Northfield, IL: CAP Press; 2018.

LSV.38560 Slide Retention Phase I

Blood films are retained for at least one week for possible review and/or reference.

NOTE: It may be desirable to retain outpatient films for a longer period and significantly abnormalfilms indefinitely for teaching purposes.

LSV.38580 Morphology Assessment - PLT/RBC Phase II

The laboratory staff fully assesses, and accurately reports, RBC and PLT morphology aspart of the performance of a WBC differential and/or blood film review.

NOTE: The laboratory must have a system to ensure that technical personnel have fullyassessed all morphologic findings in each patient film. Each laboratory director should, inconsultation with the medical staff, determine which morphologic findings are reportable.For example, minor degrees of anisocytosis and poikilocytosis without specific types of RBC

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abnormalities may be considered within the normal spectrum and not reportable to the chart. ForRBC abnormalities that are reported, the laboratory must define a qualitative or semiquantitativegrading system. When defined abnormalities (eg, spherocytes, target cells, fragments, etc.) arepresent, non-specific listings of "anisocytosis" and/or "poikilocytosis" may not provide additionalclinically useful information.

Evidence of Compliance:✓ Written procedure defining the criteria for microscopic assessment of RBC and platelet

morphology✓ Patient reports that show assessment and reporting of RBC and PLT morphology

REFERENCES1) Napoli V, et al. A semiquantitative estimate method for reporting abnormal RBC morphology. Lab Med. 1980;11:111-116

2) Krause JR. Redcell abnormalities in the blood smear: disease correlations. Lab Mgmt. 1985;23(10):29-35

3) Bell A, Lofsness KG. A photo essay on red cell morphology. J Med Tech. 1986;3:85-93

4) Lewis SM. Blood film evaluations as a quality control activity. Clin Lab Haematol. 1990;12:119-127

LSV.38620 Criteria for Blood Film Review Phase II

There are written criteria with specified findings for blood films that must be reviewedby the pathologist, supervisor or other technologist qualified in hematomorphology, andthere is evidence of such review.

REFERENCES1) Peterson P, et al. Physician review of the peripheral blood smear: when and why. An opinion. Lab Hematol. 2001;7:175-179

2) Gulati GL, et al. Criteria for blood smear review. Lab Med. 2002;33:374-377

AUTOMATED RETICULOCYTES


● Automated reticulocyte procedure● Sampling of QC records

LSV.38648 Spurious Reticulocyte Results Phase I

There is a written procedure to detect spurious automated reticulocyte results prior toreporting.

NOTE: Since all DNA- and RNA-containing cells will stain with DNA-RNA fluorescent dyes,the written procedure must identify when the instrument cannot discriminate such stainedparticles from true reticulocytes. Potential interferences include Howell-Jolly bodies, nucleatederythrocytes, Heinz bodies, basophilic stippling of red cells, macrothrombocytes, megakaryocytefragments, platelet clumps, and malaria or other intracellular organisms. Erythrocyte agglutinationalso may give spuriously high results, as may very high leukocytosis or thrombocytosis.Interfering particles may vary, depending on instrumentation, dye, and reaction conditions.Based upon initial evaluation of the instrument by the laboratory, criteria must be developed todetect samples with potentially erroneous results. This may be accomplished through flaggingalgorithms incorporated in the instrument and by examination of a blood film from every sampleto ensure absence of relevant interferences.

Evidence of Compliance:✓ Written procedure to detect spurious automated reticulocyte results AND✓ Records showing actions taken to verify reticulocyte count prior to reporting

REFERENCES

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1) Jacobberger HW, et al. Flow cytometric analysis of blood cells stained with the cyanine dye Dioc1[3]: reticulocyte quantification.Cytometry. 1984;5:589-600

2) Davis BH, et al. Utility of flow cytometric reticulocyte quantification as a predictor of engraftment in autologous bone marrowtransplantation. Am J Hematol. 1989;32:81-87

3) Davis BH, Bigelow NC. Flow cytometric quantification using thiazole orange provides clinically useful reticulocyte maturity index. ArchPathol Lab Med. 1989;113:684-689

4) Hackney JR, et al. Automated reticulocyte counting by image analysis and flow cytometry. Lab Med. 1989;20:551-555

5) Coulet M, Bezou MJ. Utilization of the automated reticulocyte counter Sysmex R1000. Sysmex J. 1990;13:393-406

6) Wells DA, et al. Effect of iron status on reticulocyte mean channel fluorescence. Am J Clin Pathol. 1992;97:130-134

7) Riley RS, Ross W. Reticulocyte enumeration, In: Riley RS, Makin EJ, Ross W, eds. Clinical applications of flow cytometry. New York,NY: Igaku-shoin, 1993:582-611

8) Batjer JD, et al. Predicting bone marrow transplant engraftment by automated flow cytometric reticulocyte analysis. Lab Med.1994;25:22-26

9) Lofsness KG, et al. Evaluation of automated reticulocyte counts and their reliability in the presence of Howell-Jolly bodies. Am J ClinPathol. 1994;101:85-90

MANUAL RETICULOCYTES


● Manual reticulocyte procedure

● Reticulocyte blood smear (uniquely identified, properly stained, free of precipitate,good cell distribution)

LSV.38650 Reticulocyte Blood Film Quality Phase I

The quality of reticulocyte blood films is satisfactory (properly stained, free of precipitate,good cell distribution).

REFERENCES1) Fannon M, et al. Effect of staining and storage times on reticulocyte counts. Lab Med. 1982;13:431-433

LSV.38652 Reporting - Retics Phase I

The reported reticulocyte concentration is based on a minimum sample size of 1,000 RBC.

NOTE: Commercial controls are not necessary for manual reticulocyte counts.

Evidence of Compliance:✓ Written procedure for manual reticulocyte counts including the method, number of cells

counted and calculations used

REFERENCES1) Greenberg ER, Beck R. The effects of sample size on reticulocyte counting and stool examination. The binomial and Poisson

distributions in laboratory medicine. Arch Pathol Lab Med. 1984;108:396-3982) Savage RA, et al. Analytic inaccuracy and imprecision in reticulocyte counting: a preliminary report from the College of American

Pathologists reticulocyte project. Blood Cells. 1985;11:97-1123) Koepke JA. Update on reticulocyte counting. Lab Med. 1999;30:339-343

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ABNORMAL HEMOGLOBIN DETECTION

For purposes of diagnosing hemoglobinopathies, more than one test may be necessary. As an example,hemoglobin solubility testing alone is not sufficient for detecting or confirming the presence of sicklinghemoglobins in all situations. If methods other than solubility testing are performed, the Hematology andCoagulation Checklist or Chemistry and Toxicology Checklist must be used for inspection.


● Sampling of abnormal hemoglobin policies and procedures● Sampling of patient reports (confirmatory testing, comments)● Sampling of QC records

● What is your course of action when the primary screening method appears to showHb S?

LSV.38658 Hb S Primary Screen Phase II

For samples that appear to have Hb S in the primary screening (by any method), thelaboratory either 1) performs a second procedure (solubility testing, or other acceptablemethod) to confirm the presence of Hb S, or 2) includes a comment in the patient reportrecommending that confirmatory testing be performed.

NOTE: For primary definitive diagnosis by electrophoresis or other separation methods, allsamples with hemoglobins migrating in the "S" positions or peak must be tested for solubilityor by other acceptable confirmatory testing for sickling hemoglobin(s). Known sickling andnonsickling controls both must be included with each run of patient specimens tested.

Evidence of Compliance:✓ Written policy defining criteria for follow-up when Hb S appears in the primary screen

BONE MARROW PREPARATIONS

This section is to be used for laboratories that assist with the collection of bone marrow specimens and thepreparation of slides. Laboratories that perform special stains and/or interpret bone marrow slides must beinspected with the Hematology and Coagulation Checklist or the Anatomic Pathology Checklist.


● Bone marrow policy and procedure

LSV.38663 Bone Marrow Slide Quality Phase I

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The quality of bone marrow aspirate and touch slide preparations are satisfactory(properly stained, free of precipitate).

**REVISED** 09/17/2019LSV.38664 Bone Marrow Procedures Phase II

If bone marrow aspiration and/or biopsy procedures are performed, there is a writtenprocedure to verify patient identification using at least two patient identifiers, theprocedure site, and the procedure to be performed.

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Accuracy in Patient and Specimen Identification. 2nd ed. CLSI standard GP33.

Clinical and Laboratory Standards Institute, Wayne, PA; 2019.

RESULTS REPORTING - HEMATOLOGY


● Sampling of reporting policies and procedures● Sampling of patient reports (reference intervals)

● How have you established or verified reference intervals?

**REVISED** 09/17/2019LSV.38667 Reference Intervals Phase II

Patient results are reported with accompanying reference intervals or interpretive ranges.

NOTE: For WBC differential counts, the CAP recommends that laboratories report absolute cellcounts, along with their corresponding reference intervals. The CAP discourages the reportingof percent cell counts without absolute counts on WBC differentials. Laboratories reporting onlypercent cell counts must provide laboratory established reference intervals.

Under some circumstances it may be appropriate to distribute lists or tables of reference intervalsto all users and sites where reports are received. This system is usually fraught with difficulties,but if in place and rigidly controlled, it is acceptable.

Reference interval citations from the manufacturer's insert or published literature citations may beused to determine the reference interval. However, reference intervals have not been publishedfor many body fluid analytes and obtaining normal fluids to establish reference intervals maynot be feasible. If reference intervals are not available, results must be accompanied by anappropriate comment such as, "The reference interval(s) and other method performancespecifications are unavailable for this body fluid. Comparison of the result with concentration inthe blood, serum, or plasma is recommended."

REFERENCES1) Trost DC, et al. Probability-based construction of reference ranges for ratios of log-Gaussian analytes: an example from automated

leukocyte counts. Am J Clin Pathol. 2002;117:851-8562) Clinical and Laboratory Standards Institute (CLSI). Defining, Establishing, and Verifying Reference Intervals in the Clinical Laboratory

- Approved Guideline- Third Edition - CLSI Document EP28-A3C. (ISBN 1-56238-682-4) Clinical and Laboratory Standards Institute,940 West Valley Road, Suite 2500, Wayne, PA, 19087-1898, USA, 2010.

3) Etzell, JE. For WBC differentials reporting absolute numbers. CAP Today. 2010; 3:12

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4) Richardson-Jones A, Twedt D, Hellman R. Absolute versus proportional differential leukocyte counts. Clin Lab. Haem. 1995:17(2),115-123

COAGULATION SECTION

SPECIMEN COLLECTION AND HANDLING - COAGULATION


● Sampling of coagulation specimen collection and handling policies and procedures● Sampling of specimen rejection records/log

● Sampling of patient coagulation specimens (anticoagulant, labeling)

● How do you know if the specimen is clotted?● What further actions are necessary if the specimen has a hematocrit of 60%?● What is your course of action when you receive unacceptable coagulation

specimens?● How do you ensure that platelet-poor plasma is used for testing?

LSV.38669 Specimen Collection - Intravenous Lines Phase I

There is a documented policy regarding clearing (flushing) of the volume of intravenouslines before drawing samples for hemostasis testing.

NOTE: Collection of blood for coagulation testing through intravenous lines that have beenpreviously flushed with heparin should be avoided, if possible. If the blood must be drawnthrough an indwelling catheter, possible heparin contamination and specimen dilution should beconsidered. When obtaining specimens from indwelling lines that may be contain heparin, theline should be flushed with 5 mL of saline, and the first 5 mL of blood or 6-times the line volume(dead space volume of the catheter) be drawn off and discarded before the coagulation tube isfilled. For those samples collected from a normal saline lock (capped off venous port) twice thedead space volume of the catheter and extension set should be discarded.

REFERENCES1) Lew JKL, et al. Intra-arterial blood sampling for clotting studies. Effects of heparin contamination. Anesthesia. 1991;46:719-721

2) Konopad E, et al. Comparison of PT and aPTT values drawn by venipuncture and arterial line using three discard volumes. Am J CritCare. 1992;3:94-101

3) Laxson CJ, Titler MG. Drawing coagulation studies from arterial lines; an integrative literature review. Am J Critical Care. 1994;1:16-24

4) Adcock DM, et al. Are discard tubes necessary in coagulation studies? Lab Med. 1997;28:530-533

5) Brigden ML, et al. Prothrombin time determination. The lack of need for a discard tube and 24-hour stability. Lab Med.1997;108:422-426

6) Clinical and Laboratory Standards Institute (CLSI). Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays and Molecular Hemostasis Assays; Approved Guideline—Fifth Edition. CLSI Document H21-A5 (ISBN1-56238-657-3). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898 USA, 2008.

7) Clinical and Laboratory Standards Institute. Collection of Diagnostic Venous Blood Specimens; 7th ed. CLSI standard GP41-ED7.Clinical and Laboratory Standards Institute, Wayne, PA, 2017.

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LSV.38672 Anticoagulant - Coagulation Phase I

Routine coagulation specimens are collected into 3.2% buffered sodium citrate.

NOTE: Sodium citrate is effective as an anticoagulant due to its mild calcium-chelatingproperties. Of the 2 commercially available forms of citrate, 3.2% buffered sodium citrate(105-109 mmol/L of the dihydrate form of trisodium citrate Na3C6H5O7·2H2O) is therecommended anticoagulant for coagulation testing. Reference intervals for clot-based assaysshould be determined using the same concentration of sodium citrate that the laboratoryuses for patient testing. The higher citrate concentration in 3.8% sodium citrate, may result infalsely lengthened clotting times (more so than 3.2% sodium citrate) for calcium-dependentcoagulation tests (ie, PT and aPTT) performed on slightly underfilled samples and sampleswith high hematocrits. The prolonged results are also more pronounced when the clotting timeis abnormal, such as in samples from patients on warfarin therapy. Both the World HealthOrganization and CLSI recommend utilizing 3.2% sodium citrate (105-109 nm/L), as thethromboplastin International Sensitivity Index (ISI) values applied in the INR calculations arebased on specimens collected in 3.2% sodium citrate. Coagulation testing cannot be performedin samples collected in EDTA due to the more potent calcium chelation. While certain assaysystems, such as platelet mapping via thromboelastography require heparin, heparinizedtubes are not appropriate for clot-based plasma assays due to the inhibitory effect of heparinon multiple coagulation proteins. Other testing for platelet function, such as light transmissionplatelet aggregation assay can be performed on 3.2% or 3.8% sodium citrate.

Evidence of Compliance:✓ Written policy defining the use of 3.2% buffered sodium citrate for coagulation specimen

collection AND/OR✓ Written procedure for use of an alternative anticoagulant that follows manufacturer's

instructions or has been validated by the laboratory

REFERENCES1) Adcock DM, et al. Effect of 3.2% vs 3.8% sodium citrate concentration on routine coagulation testing. Am J Clin Pathol.

1997;107:105-1102) Reneke, J et al. Prolonged prothrombin time and activated partial thromboplastin time due to underfilled specimen tubes with 109

mmol/L (3.2%) citrate anticoagulant. Am J Clin Pathol. 1998;109:754-7573) Clinical and Laboratory Standards Institute (CLSI). Collection, Transport, and Processing of Blood Specimens for Testing Plasma-

Based Coagulation Assays and Molecular Hemostasis Assays; Approved Guideline—Fifth Edition. CLSI Document H21-A5 (ISBN1-56238-657-3). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898 USA, 2008.

LSV.38683 Fill Volume - Coagulation Phase I

There are written guidelines for the acceptable fill volume of specimen collection tubes forcoagulation testing.

NOTE: The recommended proportion of blood to the sodium citrate anticoagulant volume is 9:1.Inadequate filling of the collection device will decrease this ratio, and may lead to inaccurateresults for calcium-dependent clotting tests, such as the PT and aPTT. The effect on clotting timefrom under-filled tubes is more pronounced when samples are collected in 3.8% rather than 3.2%sodium citrate. The effect of fill volume on coagulation results also depends on the reagent usedfor testing, size of the evacuated collection tube, and citrate concentration. A minimum of 90% fillis recommended; testing on samples with less than 90% fill should be validated by the laboratory.It is unacceptable to combine the contents from separate, underfilled sodium citrate collectiontubes.

Evidence of Compliance:✓ Records of rejected specimens

REFERENCES1) Peterson P, Gottfried EL. The effects of inaccurate blood sample volume on prothrombin time (PT) and activated partial

thromboplastin time. Thromb Haemost. 1982;47:101-1032) Adcock DM, Kressin D, Mariar PA. Minimum specimen volume requirements for routine coagulation testing. Dependence on citrate

concentration. Am J Clin Pathol. 1998;109:595-5993) Reneke J, et al. Prolonged prothrombin time and activated partial thromboplastin time due to underfilled specimen tubes with 109

mmol/L (3.2%) citrate anticoagulant. Am J Clin Pathol. 1998;109:754-757

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LSV.38685 Elevated Hematocrits - Coagulation Phase I

There are written guidelines for detection and special handling of specimens with elevatedhematocrits.

NOTE: A hematocrit value >55% may lead to spurious coagulation results. The citrateanticoagulant distributes only in the plasma and not into the blood cells. For this reason,plasma citrate concentration will be increased if the patient's hematocrit is greater than 55%,potentially leading to spuriously prolonged PT and aPTT results, as well as erroneous resultsfor other calcium-dependent clotting tests such as clottable protein C/protein S and factorassays. Accordingly, a written procedure for the detection and special handling of polycythemicspecimens is required. If possible, a new phlebotomy should be performed, using a reducedvolume of sodium citrate, adjusted for the elevated hematocrit. Conversely, there are no currentdata to support a recommendation for adjusting the citrate concentration in the presence ofsevere anemia (hematocrit <20%).

Evidence of Compliance:✓ Written procedure outlining the detection and handling of coagulation specimens with

elevated hematocrits AND✓ Written procedure for the adjustment of citrate concentration for coagulation specimens with

a known hematocrit >55%

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Collection, Transport, and Processing of Blood Specimens for Testing Plasma-


2) Siegel JE, et al. Effect (or lack of it) of severe anemia on PT and APTT results. Am J Clin Pathol. 1998; 110:106-110

3) Siegel JE, et al. Monitoring heparin therapy. APTT results from partial- vs full-draw tubes. Am J Clin Pathol. 1998;110:184-187

4) Mariar RA, et al. Effect on routine and special coagulation testing values of citrate anticoagulant adjustment in patients with highhematocrit values. Am J Clin Pathol. 2006: 126:400-405

5) Goodwin AJ. Q & A: Should a patient with a hematocrit greater than 55 percent be redrawn for correction always or only whenprothrombin time and partial prothrombin time are elevated? CAP Today. August 2016.

**REVISED** 06/04/2020LSV.38690 Specimen Quality Assessment - Coagulation Phase II

Coagulation specimens are checked for clots (eg, applicator sticks) or by analysis oftesting results (eg, wave form analysis, delta checks) before reporting results.

NOTE: Specimens with grossly visible clots may have extremely low levels of fibrinogen andvariably decreased levels of other coagulation proteins, causing PT, aPTT, fibrinogen and othercoagulation assays results to be inaccurate or unobtainable. Checking for clots may be done:

● With applicator sticks● By visual inspection of centrifuged plasma for small clots● By analysis of results including waveform analysis or delta checks as applicable

Laboratories receiving centrifuged specimens (eg, frozen plasma) cannot rely on visualinspection alone to detect specimen quality issues. For example, if a clot is not detected duringPT and aPTT testing and the fibrinogen level is <25 mg/dL, the sample may actually be seruminstead of plasma.

The laboratory must have a written policy to identify these specimens appropriately and/orto reject specimens, as applicable. Laboratories must work with their clients that performspecimen processing to ensure that they practice appropriate specimen handling for coagulationspecimens.

Evidence of Compliance:✓ Written policy to assess quality of coagulation specimens AND

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✓ Records of rejection for clotted specimens



2) Arkin CF. Collection, handling, storage of coagulation specimens. Advance/Lab. 2002;11(1);33-38

LSV.38695 Specimen Handling - Coagulation Phase II

Coagulation tests are promptly performed on fresh plasma, or the platelet-poor plasma isfrozen until testing can be performed.

NOTE: After blood collection, there is progressive degradation of the labile coagulation factorsV and VIII, leading to increasing prolongation of the aPTT and PT. The allowable time intervalbetween specimen collection and sample testing depends on the temperature encounteredduring transport and storage of the specimen. Allowable time intervals are as follows:

1. PT specimens, uncentrifuged or centrifuged with plasma remaining in the cappedtube above the packed cells, or as centrifuged plasma separated from the cells,should be kept at room temperature (18 to 24°C) and tested no longer than 24hours from the time of specimen collection. PT specimens should not be refrigerated(during storage).

2. aPTT specimens that are uncentrifuged with plasma remaining in the capped tubeabove the packed cells should be kept at room temperature (18 to 24°C) and testedno longer than 4 hours after the time of specimen collection.

3. aPTT specimens that are centrifuged and plasma separated from cells can be keptfor 4 hours refrigerated (2 to 8°C) or at room temperature (18 to 24°C). Samples forunfractionated heparin testing should be centrifuged within one hour from the time ofspecimen collection

4. Samples for other coagulation factors (eg, thrombin time, protein C, factor V, factorVIII) have variable stability and should be kept in the same manner as aPTT samples

If PT or aPTT testing cannot be performed within these times, platelet-poor plasma should beremoved from the cells and frozen at –20°C for up to 2 weeks or at –70°C for up to 12 months.If a laboratory has established an allowable time interval different than that detailed above, datamust be available to verify that coagulation testing is valid in the time interval established.

Evidence of Compliance:✓ Written policy defining specimen stability requirements and sample preservation for delays in

coagulation testing



2) Adcock DM, et al. The effect of time and temperature variables on routine coagulation tests. Blood Coag Fibrinolysis. 1998;9:463-470

3) Neofotistos D, et al. Stability of plasma for add-on PT and aPTT tests. Am J Clin Pathol. 1998;109:758-763

4) Davis KD, et al. Use of different thromboplastin reagents causes greater variability in international normalized ratio results thanprolonged room temperature storage of specimens. Arch Pathol Lab Med. 1998;122:972-977

LSV.38705 Platelet Function Studies Phase II

Platelet functional studies (platelet aggregation or initial platelet function test) areperformed within an appropriate period after venipuncture.

NOTE: Following venipuncture, platelets continue to activate in vitro, so that platelet functionalitybecomes abnormal after a period of several hours. The laboratory must ensure that plateletaggregation studies are completed within 3-4 hours from the time of phlebotomy, or erroneousresults could be obtained. Manufacturer's instructions for specimen stability must be followed forFDA-cleared/approved platelet function study assays.

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Evidence of Compliance:✓ Written policy defining specimen stability for platelet function studies AND✓ Records of testing completed within the defined time period

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Platelet Function Testing by Aggregometry; Approved Guideline. CLSI document

H58-A. Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898 USA, 2008.

**NEW** 09/17/2019LSV.38707 Specimen Handling - Platelets Phase II

Blood specimens for platelet aggregation and platelet function studies are handled atroom temperature before testing.

NOTE: Platelets develop a cold-induced conformational change and dysfunction when handled attemperatures <20°C. Even when re-warmed, platelets may not regain normal function. Therefore,platelet specimens should always be handled at "room temperature," which is generally definedas 20 to 25°C (68 to 77°F) before testing and should never be refrigerated, chilled on ice orfrozen.

Evidence of Compliance:✓ Written policy defining the specimen handling requirements prior to analysis

REFERENCES1) Winokur R, Hartwig JH. Mechanism of shape change in chilled human platelets. Blood. 1995; 85:1796-1804

2) Clinical and Laboratory Standards Institute (CLSI). Platelet Function Testing by Aggregometry; Approved Guideline. CLSI documentH58-A. Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898 USA, 2008.

3) Mani H, Kitchmayr K, Klaffling C, et al. Influence of blood collection techniques on platelet function. Platelets. 2004;15(5):315-318

4) Kattlove HE, Alexander B. The effect of cold on platelets. I. Cold-induced platelet aggregation. Blood. 1971;38(1):39-48

5) Kattlove HE, Alexander B, White F. The effect of cold on Platelets. II. Platelet function after short-term storage at cold temperatures.Blood. 1972;40(5):688-695

LSV.38711 DIC Phase II

Tests for defining or monitoring disseminated intravascular coagulation (DIC) areavailable, if applicable to the patient population served.

REFERENCES1) Bovill EG. Laboratory diagnosis of disseminated intravascular coagulation. Sem Hematol. 1994;31(2;suppl)35-29

2) Clinical and Laboratory Standards Institute. Procedure for Determining Packed Cell Volume by the Microhematocrit Method;Approved Standard; 3rd ed. CLSI document H07-A3. CLSI, Wayne, PA, 2000.

3) Clinical and Laboratory Standards Institute. Procedure for the Determination of Fibrinogen in Plasma; Approved Guideline; 2nd ed.CLSI document H30-A2. CLSI, Wayne, PA, 2001.

4) Yu M, et al. Screening tests of disseminated intravascular coagulation: guidelines for rapid and specific laboratory diagnosis. CritCare Med. 2000;28:1777-1780

5) Kotke-Marchant K (ed). An Algorithmic Approach to Hemostasis Testing. CAP Press: 2008

LSV.38716 Coagulation Testing and Anticoagulant Recommendations Phase I

Recommendations are available to clinicians on the following:

● Laboratory tests used for monitoring heparin, low molecular weight heparin,direct thrombin inhibitors (eg, lepirudin, bivalirudin, argatroban) and/or oralanticoagulant therapy

● The therapeutic range for the tests, if available● Information about potential interferences of anticoagulant medications on

coagulation testing.

NOTE: The coagulation tests available to clinicians should be applicable to the anticoagulantdrugs in use, and information is available on the test values that indicate that the anticoagulant ispresent and/or is in a therapeutic range, when available.

For vitamin K antagonists (eg, warfarin), the prothrombin time (PT/INR) is recommended. Directoral anticoagulant medications (non-vitamin K) should not be monitored with PT/INR or aPTT

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because the effect of these tests is not predictable. For unfractionated heparin the activatedpartial thromboplastin time (aPTT) and/or activated clotting time are commonly used, but theheparin assay (factor Xa inhibition) may also be employed. For low molecular weight heparinor danaparoid, monitoring is often not necessary, but the heparin assay (Xa inhibition assay)may be used in certain circumstances, as the aPTT is generally insensitive to the effect of theseagents. Direct parenteral thrombin inhibitors are often monitored using the aPTT. The thrombintime may be useful to qualitatively verify the presence of direct thrombin inhibitors.

Evidence of Compliance:✓ Memorandums to physicians, test reference guide, interpretive comments in patient

reports, or other mechanism for providing recommendations to physicians for orderingand interpreting coagulation tests used for diagnostic purposes and anticoagulant therapymonitoring

REFERENCES1) Leech BF, Carter CJ. Falsely elevated INR results due to the sensitivity of a thromboplastin reagent to heparin. Am J Clin Pathol.

1998;109:764-7682) Fairweather RB, et al. College of American Pathologists conference XXXI on laboratory monitoring of oral anticoagulant therapy.

Arch Pathol Lab Med. 1998;122:768-7813) Olson JD, et al. College of American Pathologists conference XXXI on laboratory monitoring of oral anticoagulant therapy. Laboratory

monitoring of unfractionated heparin therapy. Arch Pathol Lab Med. 1998;122:782-7984) Davis KD, et al. Use of different thromboplastin reagents causes greater variability in international normalized ratio results than

prolonged room temperature storage of specimens. Arch Pathol Lab Med. 1998;122:972-9775) Laposata M, et al. College of American Pathologists conference XXXI on laboratory monitoring of low-molecular-weight heparin,

danaparoid, hirudin and related compounds, and argatroban. Arch Pathol Lab Med. 1998;122:799-8076) Smythe MA, et al. Use of the activated partial thromboplastin time for heparin monitoring. Am J Clin Pathol. 2001;115:148-155

7) Smythe MA, et al. Different heparin lots. Does it matter? Arch Pathol Lab Med. 2001;125:1458-1462

8) Hirsh J, et al. Heparin and low-molecular-weight heparin: Mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy andsafety. Chest. 2001; 119:64s-94s

9) Hirsh J, et al. Guide to anticoagulant therapy. Heparin: a statement for healthcare officials from the American Heart Association.Circulation. 2001 19:2994-3018

10) Lippi G and Favaloro EJ. Recent guidelines and recommendations for laboratory assessment of the direct oral anticoagulants(DOACs): is there consensus? Clin Chem Lab Med. 2015; 53(2):185-197.

11) Tomaselli GF, Mahaffey KW, Cuker A, et al. 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patientson Oral Anticoagulants: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J AmColl Cardiol. 2017; 70(24):3042-67.

12) Cuker A, Siegal D. Monitoring and reversal of direct oral anticoagulants. Hematology Am Soc Hematol Educ Program.2015(1):117-124.

13) Adcock DM, Gosselin R. Direct Oral Anticoagulants (DOACs) in the Laboratory: 2015 Review. Thromb Res. 2015; 136(1):7-12.

14) College of American Pathologists. Coagulation Limited Proficiency Testing - Participant Summary Report (CGL-B 2016: TherapeuticAnticoagulants) Continuing Education: 46-58. Published July 2016.

15) Funk DM. Coagulation assays and anticoagulant monitoring. Hematology Am Soc Hematol Educ Program. 2012(1):460-5.

16) Kottke-Marchant K, ed. An Algorithmic Approach to Hemostasis Testing. 2nd ed. Northfield, IL: CAP Press; 2016:379-402.

17) Favaloro EJ, Lippi G. Interference of direct oral anticoagulants in haemostasis assays: high potential for diagnostic false positivesand false negatives. Blood Transfus. 2017; Oct; 15(6):491-494.

LSV.38718 Platelet-Poor Plasma Phase I

At least annually and after major centrifuge maintenance or service, the laboratorymeasures the actual platelet count of the "platelet-poor" plasma used for manycoagulation tests.

NOTE: Platelet-poor plasma is particularly important when testing for the presence of a lupusanticoagulant, when measuring the level of unfractionated heparin, and in plasma samples tobe frozen for later testing. Platelet-poor plasma should have a residual platelet concentration

of less than 10 X 10 9/L. This is important because platelet membranes form a procoagulantsurface that can accelerate coagulation and spuriously shorten clotting times. It is particularlyimportant when testing for the presence of a lupus anticoagulant; due to the high content of lipidin the platelet plasma membrane, increased platelets in samples with the lupus anticoagulant cancause the antiphospholipid antibody to bind to the platelet membrane, thus effectively removingit from plasma. In this circumstance, the presence of lupus anticoagulant may not be detectedduring diagnostic testing. Use of a 0.2-µm filter to achieve platelet-poor plasma samples is notappropriate for all plasma-based coagulation studies. Filtration of plasma can result in selectiveremoval of factors V, VIII, IX, XII, and vWF; thus filtration of plasma to achieve a platelet-poorspecimen is discouraged. aPTT, prothrombin time/international normalized ratio (PT/NR) and

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thrombin clotting time (TT) performed on fresh plasma samples are not affected by platelet

counts of at least up to 200 x 10 9/L (200,000/µL).

Samples to be frozen should be "platelet-poor” because plasma contaminated with significantnumbers of platelets may yield different analytic results after thawing, due to lysis of platelets.

Evidence of Compliance:✓ Written procedure for measuring platelet concentration of platelet-poor plasma AND✓ Records of platelet concentration checks on all centrifuges used to prepare platelet-poor

plasma

REFERENCES1) Lupus Anticoagulant Working Party. Guidelines on testing for the lupus anticoagulant. J Clin Pathol. 1991;44:885-889

2) Middleton AL, Oakley E. Activated partial thromboplastin time (aPTT): Review of Methods. Chicago, IL: American Society of ClinicalPathology Check Sample PTS 91-8, 1991

3) Brien W, et al. Lupus anticoagulant testing: effect of the platelet count on the activated partial thromboplastin time. Brit J Biomed Sci1993;50:114-116


5) Barnes PW, Eby CS, Lukoszyk M. Residual platelet counts in plasma prepared for routine coagulation testing with the BeckmanCoulter power processor. Lab Hematol. 2002;8:205-209

6) Favaloro EJ, Lippi B, Adcock DM. Preanalytical and postanalytical variables: The leading causes of diagnostic error in hemostasis?Sem in Thromb Haem, 2008; 34:612-634

7) van den Besselaar AMHP, et al. Monitoring heparin therapy by the activated partial thromboplastin time--the effect of pre-analyticalconditions. Thromb Haemost, 1990; 57(2):226-231

QUALITY CONTROL - COAGULATION


● Sampling of quality control policies and procedures● Sampling of QC records



LSV.38720 Coagulation Quality Control Phase II

Controls are run using two different levels of control material each eight hours of patienttesting and each time there is a change in reagents, or more frequently if specified inmanufacturer's instructions, laboratory procedure, or the CAP Checklist.

NOTE: This includes photo-optical, electromechanical and manual methods.

For manual methods (ie, tilt tube method), controls must be performed by each individual whoperforms the tilt tube test in the same eight hour period.

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Evidence of Compliance:✓ Records of QC results including external and internal control processes AND✓ Written quality control procedures AND✓ Manufacturer product insert or manual


CLIA fee collection; correction and final rule. Fed Register. 2003(Jan 24):5232 [42CFR493.1269(b)].2) Steindel SJ, Tetrault G. Quality control practices for calcium, cholesterol, digoxin, and hemoglobin. A College of American

Pathologists Q-Probes study in 505 hospital laboratories. Arch Pathol Lab Med 1998;122:401-4083) Voss EM, et al. Determining acceptability of blood glucose meters. Statistical methods of determining error. Lab Med.

1996;27:601-6064) Clinical and Laboratory Standards Institute (CLSI). Statistical Quality Control for Quantitative Measurement Procedures: Principles


5) Ye JJ, et al. Performance evaluation and planning for patient/client-based quality control procedures. Am J ClinPathol.2000;113:240-248

6) LaBeau KM, et al. Quality control of test systems waived by the clinical laboratory improvement amendments of 1988. Perceptionsand practices. Arch Pathol Lab Med. 2000;124:1122-1127

7) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvementamendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1269(b) & 42CFR.493.1269(c)(2)]

COAGULATION TESTS BASED ONDIRECT MEASUREMENT OF ANALYTES

CAP accredited chemistry laboratories have been applying the concepts and procedures for calibration,calibration verification, and analytic measurement range verification (AMR) to calibrated analytical methods formany years. Section directors and technologists with chemistry backgrounds will be helpful consultants to theircoagulation laboratory colleagues as calibration verification and AMR verification requirements evolve.

The checklist requirements apply to hemostasis test methods that are calibrated and directly measure theconcentration or activity of an analyte by employing enzyme immunoassay (EIA), including ELISA andfluorescence immunoassay, immunoturbidity and chromogenic methods. Examples of commonly performedhemostasis tests affected by these checklist requirements include: calibrated EIA or immunoturbidity methodsfor coagulation factors, protein C antigen, free and total protein S antigens, von Willebrand factor antigen,von Willebrand collagen binding activity, and quantitative D-dimer, and calibrated chromagenic assays forantithrombin activity, protein C activity, and heparin or low molecular weight heparin. This list is not exhaustive,and laboratory directors should review their laboratory's test menu to identify additional tests which fall into thecategories of methodologies described above.

Clot-based methods, (including PT, aPTT, thrombin time, factor assays and fibrinogen, lupus anticoagulant,activated protein C resistance, qualitative and semi-quantitative assays) and all platelet function assays,including ristocetin cofactor activity are exempt.

NOTE: Explanatory notes and definitions on calibration, calibration verification and analytical measurementrange verification are found in the Chemistry section of the Limited Service Laboratory Checklist. The masterversion of the checklist may be downloaded using e-LAB Solutions on the CAP website.

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● Sampling of calibration/calibration verification records

● Sampling of calibration materials (labeling, storage, quality)

● What is your course of action if results fall outside the AMR?● When was the last time you performed a calibration procedure for directly measured

coagulation analytes? How did you verify the calibration?

**REVISED** 09/17/2019LSV.38743 Calibration Procedures Phase II

Calibration procedures for each test system are appropriate, and the calibration recordsare reviewed for acceptability.

NOTE: Calibration must be performed following manufacturer's instructions, at minimum,including the number, type, and concentration of calibration materials, frequency of calibration,and criteria for acceptable performance. Calibration procedures are typically specified in themanufacturer's instructions but may also be established by the laboratory.

REFERENCES1) Department of Health and Human Services, Centers for Medicare & Medicaid Services. Clinical laboratory improvement amendments

of 1988; final rule. Fed Register. 1992(Feb 28):7165 [42CFR493.1217]2) Department of Health and Human Services, Centers for Medicare & Medicaid Services. Medicare, Medicaid and CLIA Programs;

Laboratory Requirements Relating to Quality Systems and Certain Personnel Qualifications; final rule. Fed Register. 2003(Jan24):3707 [42CFR493.1255]

3) Clinical and Laboratory Standards Institute. Evaluation of Matrix Effects; Approved Guideline. 3rd ed. CLSI Document EP14-A3.Clinical and Laboratory Standards Institute, Wayne, PA; 2014

4) Miller WG. Quality control. In: Henry's Clinical Diagnostic and Management by Laboratory Methods, 21st Edition, ed McPherson RA,Pincus MR. Saunders Elsevier, 2007 :99-111.

**NEW** 09/17/2019LSV.38744 Calibration and Calibration Verification Materials Phase II

High quality materials with test system and matrix-appropriate target values are used forcalibration and calibration verification whenever possible.

NOTE: Calibration and calibration verification must have defined analyte target values andappropriate matrix characteristics for the clinical specimens and specific assay method. Manyinstrument systems require calibration materials with system-specific target values to produceaccurate results for clinical specimens.

Suitable materials for calibration verification include, but are not limited to:1. Calibrators used to calibrate the analytical system2. Materials provided by the manufacturer for the purpose of calibration verification3. Previously tested unaltered patient/client specimens4. Primary or secondary standards or reference materials with matrix characteristics

and target values appropriate for the method5. Third party general purpose reference materials that are suitable for verification

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In general, routine control materials and proficiency testing materials are not suitable forcalibration verification, except in situations where the material has been shown to be suitable (eg,specifically designated by the method manufacturer) or no other materials are available.

Evidence of Compliance✓ Written policy defining appropriate calibration and calibration verification materials

REFERENCES1) ISO 17511:2003 In vitro diagnostic medical devices--Measurement of quantities in biological samples--Metrological traceability of

values assigned to calibrators and control materials.

**REVISED** 09/17/2019LSV.38745 Recalibration/Calibration Verification Criteria Phase II

Written criteria are established for frequency of recalibration or calibration verification,and the acceptability of results.

NOTE: Laboratories must either recalibrate or perform calibration verification at least every sixmonths and if any of the following occur:

1. At changes of reagent lots unless the laboratory can demonstrate that the use ofdifferent lots does not affect the accuracy of patient/client results

2. If QC shows an unusual trend or shift or is outside acceptable limits, and the systemcannot be corrected to bring control values into the acceptable range

3. After major preventive maintenance or change of critical instrument component4. When recommended by the manufacturer

Single use devices, and other test devices that do not allow user calibration, do not requirecalibration verification.

Evidence of Compliance:✓ Written policy defining the method, frequency and limits of acceptability of calibration



amendments of 1988; final rule. Fed Register. 2003(Jan 24):3707[42CFR493.1255(b)(3)]2) Miller WG. Quality control. In: Henry's Clinical Diagnostic and Management by Laboratory Methods, 21st Edition, ed McPherson RA,

Pincus MR. Saunders Elsevier, 2007: 99-111.


The test system is recalibrated when calibration verification fails to meet the establishedcriteria of the laboratory.

Evidence of Compliance:✓ Written policy defining criteria for recalibration AND✓ Records of recalibration, if calibration or calibration verification has failed



**NEW** 09/17/2019LSV.38748 AMR Verification Materials Phase II

Verification of the analytical measurement range (AMR) is performed with matrix-appropriate materials, which, at a minimum, include the low, mid and high range of theAMR, and appropriate acceptance criteria are defined.

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NOTE: The matrix of the sample (ie, the environment in which the sample is suspendedor dissolved) may influence the measurement of the analyte. In many cases, the methodmanufacturer will recommend suitable materials. Other suitable materials for AMR verificationinclude the following:

1. Linearity material of appropriate matrix, eg, CAP CVL Survey-based or other suitablelinearity verification material

2. Previously tested patient/client specimens, that may be altered by admixturewith other specimens, dilution, spiking in known amounts of an analyte, or othertechnique

3. Primary or secondary standards or reference materials with matrix characteristicsand target values appropriate for the method

4. Patient samples that have reference method assigned target values5. Control materials, if they adequately span the AMR and have method specific target

values

Evidence of Compliance:✓ Written policy for AMR verification defining the types of materials used and acceptability

criteria


amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1255]2) Anne Ford. As coag tests evolve, so do checklist requirements. Northfield, IL; College of American Pathologists. CAP Today

November 20123) Shah VP, Midha KK, Dighe S, et al. Bioanalytical Method Validation - Pharm Res. 1992;9(4):588-92.

4) Hartmann C, Smeyers-Verbeke J, Massart DL, McDowall RD. Validation of bioanalytical chromatographic methods. J Pharm BiomedAnal. 1998;17(2):193-218.

5) Findlay JW et al. Analytical Methods Validation - Bioavailability, Bioequivalence and Pharmacokinetic Studies. Pharm Res.2000;17(12):1551-7.

6) Killeen AA, Long T, Souers R, Styler P, Ventura CB, Klee GG. Verifying Performance Characteristics of Quantitative AnalyticalSystems: Calibration Verification, Linearity, and Analytical Measurement Range. Arch Pathol Lab Med. 2014:138(9): 1773-81.

**REVISED** 09/17/2019LSV.38750 AMR Verification Phase II

Verification of the analytical measurement range (AMR) is performed at least every sixmonths and following the defined criteria. Records are retained.

NOTE: The AMR must be verified at least every six months after a method is placed in serviceand if any of the following occur:

1. A change of reagent lots unless the laboratory can demonstrate that the use ofdifferent lots does not affect the accuracy of patient/client results, and the range usedto report patient/client test data.


3. After major preventive maintenance or change of a critical instrument component4. When recommended by the manufacturer

It is not necessary to independently verify the AMR if the calibration of an assay includescalibrators that span the full range of the AMR, with low, midpoint and high vales (ie, three points)and the system is calibrated at least every six months. A one-point or two-point calibration doesnot include all of the necessary points to validate the AMR.

AMR verification is not required for clot-based coagulation tests, platelet function tests, andother tests where output is a unit of time or arbitrary reporting unit (rather than measured analyteconcentration).

Evidence of Compliance:✓ Written policy for AMR verification defining the frequency performed AND

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✓ Records of AMR verification at least every six months


amendments of 1988; final rule. Fed Register. 2003(Jan 24):3707 [42CFR493.1255]2) Anne Ford. As coag tests evolve, so do checklist requirements. Northfield, IL; College of American Pathologists. CAP Today

November 2012

LSV.38753 Diluted or Concentrated Samples Phase II

If a result is greater than or less than the AMR, a numeric result is not reported unlessthe sample is processed by dilution, a mixing procedure or concentration so that theprocessed result falls within the AMR.

NOTE:1. A measured value that is outside the AMR may be unreliable and should not be

reported in routine practice. Dilution, a mixing procedure* or concentration of asample may be required to achieve a measured analyte activity or concentrationthat falls within the AMR. The processed result must be within the AMR before it ismathematically corrected by the concentration or dilution factor to obtain a reportablenumeric result.

2. For each analyte, the composition of the diluent solution and the appropriatevolumes of sample and diluent must be specified in the procedure manual.Specifying acceptable volumes is intended to ensure that the volumes pipetted arelarge enough to be accurate without introducing errors in the dilution ratio.

3. All dilutions, whether automatic or manual, should be performed in a way thatensures that the diluted specimen reacts similarly to the original specimen in theassay system. For some analytes, demonstrating that more than one dilution ratiosimilarly recovers the elevated concentration may be helpful.

4. This checklist requirement does not apply if the concentration or activity of theanalyte that is outside the AMR is reported as "greater than" or " less than" the limitsof the AMR.

*This procedure is termed the "method of standard additions." In this procedure, a knownquantity (such as a control) is mixed with the unknown, and the concentration of the mixture ismeasured. If equal volumes of the two samples are used, then the result is multiplied by two, theconcentration of the known subtracted, and the concentration of the unknown is the difference.

Evidence of Compliance:✓ Patient reports or worksheets

LSV.38755 Maximum Dilution Phase II

For analytes that may have results falling outside the limits of the AMR, the laboratoryprocedure specifies the maximum dilution that may be performed to obtain a reportablenumeric result.

NOTE:1. For each analyte, the laboratory protocol should define the maximum dilution that

falls within the AMR and that can be subsequently corrected by the dilution factorto obtain a reportable numeric result. Note that for some analytes, an acceptabledilution protocol may not exist because dilution would alter the analyte or the matrixcausing erroneous results. Also note that, for some analytes, there may be no clinicalrelevance to reporting a numeric result greater than a stated value.

2. Analytes for which a dilution protocol is unable to bring the activity or concentrationinto the AMR should be reported as "greater than" the highest estimated values.

3. Establishment of allowable dilutions is performed when a method is first placed intoservice and is reviewed biennially thereafter as part of the procedure manual reviewby the Laboratory Director or designee. The laboratory director is responsible for

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establishing the maximum allowable dilution of samples that will yield a crediblelaboratory result for clinical use.


COAGULATION STUDIES

PT/INR AND APTT


● Sampling of reporting policies and procedures● Sampling of patient PT/aPTT reports

● How have you established or validated your PT and aPTT reference intervals usingthe current lot numbers of PT and aPTT reagents?

● How have you established and validated your aPTT-based heparin therapeuticrange?

● How do you establish the geometric mean?

● Examine the current PT reagent lot package insert for the ISI value, lot number andinstrument model, and verify that the reagent lot number and ISI value is programmedfor the correct instrument model

● Review the data used to establish the geometric mean, and compare to that enteredinto the instrument

● Verify calculations for the current reagent lot in use and examine the lot numbervalidation records for the correct INR calculations

● Check patient reports to ensure INR and reference interval correlate with the dataobtained in the lot number conversion

● Track a PT and aPTT specimen from testing in the laboratory to results reporting.Assess the following: proper ID on tube, proper anticoagulant, acceptable QC for thatrun, critical result notification (as applicable), reference intervals on patient report,and correct INR calculation and associated parameters.

LSV.38760 Alternative Method Criteria Phase I

For photo-optical coagulation systems, guidelines are established for determining whenalternative procedures are performed (eg, lipemia, hyperbilirubinemia, turbidity, etc.).

NOTE: Very long clotting times may not be reproducible on an automated coagulationinstrument. Criteria should be established by each laboratory for performance of the PT or aPTTby an alternate technique (eg, manual method) when the readable range of the instrumentis exceeded. In addition, criteria should be provided for performance of alternate proceduresin the presence of significant hyperbilirubinemia or lipemia, paradoxically short aPTTs andnonduplicating aPTTs.

Evidence of Compliance:✓ Written policy defining criteria for when PT/aPTT alternative procedures should be performed

AND

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✓ Records showing results from alternative procedures, as applicable

REFERENCES1) Favaloro EJ, Lippi B, Adcock DM. Preanalytical and postanalytical variables: The leading causes of diagnostic error in hemostasis?

Sem in Thromb Haem, 2008; 34:612-634

LSV.38840 Clot Detection Phase II

For electromechanical coagulation systems, if the system has reusable probes to detect aclot, written guidelines for cleaning the probes are available.

LSV.38865 Duplicate Testing - Manual Testing Phase II

For manual coagulation testing (eg, PT, aPTT, fibrinogen) determinations are performed induplicate and criteria for agreement are defined.

Evidence of Compliance:✓ Records or worksheets reflecting duplicate testing of each sample including corrective action

when limits of agreement are exceeded


amendments of 1988; final rule. Fed Register. 2003(Jan 24):7168 [42CFR493.1269(c)(2]2) Clinical and Laboratory Standards Institute (CLSI). Collection, Transport, and Processing of Blood Specimens for Testing Plasma-


LSV.38870 ISI Phase II

For PT, there is a record that the ISI is appropriate to the particular PT reagent andinstrumentation used.

NOTE: The laboratory must demonstrate appropriateness of its ISI, a measurement of thesensitivity with which thromboplastin reagents detect decreased levels of vitamin K-dependentcoagulation factors. The ISI used must be appropriate for the particular reagent-instrumentcombination and method of clot detection. Acceptable records would include information fromthe instrument/reagent manufacturer or local calibration using an FDA-approved product. Thisis especially true for photo-optical vs. electromechanical instruments, but may also vary amongdifferent instruments within the same classification.

Evidence of Compliance:✓ Record showing information from the instrument/reagent manufacturer OR use of an ISI

calculated from laboratory specimens

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). One-Stage Prothrombin Time (PT) Test and Activated Partial Thromboplastin

Time (aPTT) Test; Approved Guideline-Second Edition. CLSI Document H47-A2. (ISBN 1-56238-672-7). Clinical and LaboratoryStandards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898, USA, 2008.

2) Fairweather RB, et al. College of American Pathologists Conference XXXI on laboratory monitoring of oral anticoagulant therapy.Arch Pathol Lab Med. 1998;122:768-781

3) Clinical and Laboratory Standards Institute (CLSI). Procedures for Validation of INR and Local Calibration of PT/INR Systems;Approved Guideline. CLSI document H54-A. Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne,PA 19087-1898, USA, 2005.

4) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvementamendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1252(a)]

LSV.38880 INR Calculation Adjustment for ISI Phase II

The calculation of the INR is adjusted using the appropriate ISI value for every new lot ofPT reagent, changes in types of reagent, or change in instrumentation.

NOTE: The ISI value usually changes with each new lot of PT reagent. The ISI reflects thesensitivity of the PT reagent to decreased levels of the vitamin K-dependent coagulation factors.This change in sensitivity will affect the calculation of the INR value.

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The laboratory must be able to provide records that calculation of the INR is correct and that theISI value is appropriate for the lot of thromboplastin reagent and for the method of clot detection.Such records must be available whether the INR is calculated by the coagulation instrument,laboratory information system, or manually.

It is critical to calculate and report appropriate INR values. Reporting erroneous INR values maylead to use of excessive or insufficient vitamin K antagonist medication, which may result inbleeding or thrombotic complications in patients.

Evidence of Compliance:✓ Records showing that the ISI values used in the INR calculation were appropriate for new

lots and types of PT reagent and for any other changes





LSV.38885 INR Geometric Mean Phase II

The appropriate geometric mean of the PT reference interval is used in the INRcalculation.

NOTE: The appropriate mean of the PT reference interval must be used in the INR calculation,given by the formula:

INR=(PT of patient / PT of geometric mean normal population)ISI

The mean normal population value may change when the specimen collection process,instrument, reagent lot, or reagent changes.

When the distribution of values is distributed normally, the geometric mean, the arithmetic mean,the median and the mode of the population being studied are identical theoretically. These valuesdiverge from each other; however, as the population distribution becomes more skewed. Thegeometric mean is a more appropriate estimate of the average value than the arithmetic meanwhen the population of interest is lognormally distributed because the geometric mean takesskewing into account.

Calculation of the geometric mean is indicated below; this calculation is available in manyspreadsheet programs, such as Microsoft Excel.

GM = antilog [(log(X1) + log(X2) + log(X3) + . . . log(Xn))/n].

Evidence of Compliance:✓ Written procedure for determining the geometric mean and its use in the INR calculation

AND✓ Records for geometric mean determinations and INR calculations for each instrument and PT

reagent lots used




3) Ansell J, et al. Managing oral anticoagulant therapy. Chest 2001;119:22s-38s

4) Critchfield GC, Bennett ST. The influence of the reference mean prothrombin time on the international normalized ratio. Am J ClinPathol. 1994 Dec;102(6):806-11


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LSV.38890 Report Verification Criteria Phase II

There are checks of patient reports for correct INR calculations, patient values, andreference intervals under the following circumstances.

1. Change in lot or type of PT reagent2. Change in instrument3. Establishment of new PT reference interval4. Change in INR calculation5. At defined intervals, in the absence of the above changes

NOTE: It is suggested that the calculations be checked at the following INR values: 2.0 and 3.0.Patient reports should be checked at least once per year, even in the absence of changes tothe test system and calculations. This requirement applies whether the INR is calculated by thecoagulation analyzer or by the laboratory information system.

Evidence of Compliance:✓ Records of patient report checks at defined frequency




3) Ansell J, et al. Managing oral anticoagulant therapy. Chest 2001;119:22s-38s


LSV.38895 Reference Intervals Phase II

Reference intervals for PT and aPTT are current for the reagent or lot number, and theyhave been appropriately determined.

NOTE: Because of the variability between different types of PT and aPTT reagents, and evendifferent lots of PT and aPTT reagents, there may be significant changes in the reference intervalafter a change of the type or lot of reagent. For this reason, the laboratory should establish andthen verify the reference interval with each change of lot or change in reagent.

Evidence of Compliance:✓ Written procedure for determining reference intervals for PT and aPTT AND✓ Reports showing verification of the reference interval with changes of lot or reagent AND✓ Patient reports reflecting the use of the correct reference intervals

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Defining, Establishing, and Verifying Reference Intervals in the Clinical Laboratory

- Approved Guideline- Third Edition - CLSI Document EP28-A3C. (ISBN 1-56238-682-4) Clinical and Laboratory Standards Institute,940 West Valley Road, Suite 2500, Wayne, PA, 19087-1898, USA, 2010.

**REVISED** 09/17/2019LSV.38910 Heparin Therapeutic Range Phase I

There is a record that the aPTT-based heparin therapeutic range is established andsubsequently verified using an appropriate technique.

NOTE: The heparin-responsiveness of aPTT reagents may change from lot to lot and amongdifferent reagents used on different instrument platforms. For this reason, it is necessary toestablish the heparin therapeutic range for the aPTT assay with each change of coagulationinstrument and/or reagent type. The therapeutic range must be verified with each new lot of agiven aPTT reagent.

The aPTT is commonly used to monitor the anticoagulant effects of unfractionated heparin. Thetherapeutic range for heparin therapy should be initially validated for new reagents or instruments

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by using ex vivo plasma samples anticoagulated with 3.2% sodium citrate obtained from patientsreceiving therapeutic doses of unfractionated heparin. This can be accomplished by measuringthe aPTT and heparin activity and then deriving the aPTT therapeutic range by comparison toheparin activity. For subsequent reagent lot changes, the therapeutic range can be verified bycomparing the aPTT of patient samples using the new and the prior aPTT lots. It is not bestpractice to use plasma samples spiked with heparin in vitro to calculate the therapeutic range,as differences in heparin binding proteins in vitro may lead to overestimation of the therapeuticrange.

Laboratories in a local care network or system using the same instrument and same lot of anAPTT reagent, can share their nomogram of Heparin. However, a verification study using onelaboratory as the reference laboratory to show that their results are comparable to each othermust be performed.

Anti-Xa activity is the preferred alternate method to monitor heparin therapy.

Evidence of Compliance:✓ Written procedure for establishing and validating the aPTT heparin therapeutic range

REFERENCES1) Rosborough TK. Comparison of anti-factor Xa heparin activity and activated partial thromboplastin time in 2,773 plasma samples

from unfractionated heparin-treated patients. Am J Clin Pathol. 1997;108:662-6682) Olson JD, et al. College of American Pathologists conference XXXI on laboratory monitoring of anticoagulant therapy. Laboratory

monitoring of unfractionated heparin therapy. Arch Pathol Lab Med. 1998;122:782-7983) Smythe MA, et al. Use of the activated partial thromboplastin time for heparin monitoring. Am J Clin Pathol. 2001;115:148-155

4) Smythe MA, et al. Different heparin lots. Does it matter? Arch Pathol Lab Med. 2001;125:1458-1462

5) Hirsh J, et al. Guide to anticoagulant therapy. Heparin: a statement for healthcare officials from the American Heart Association.Circulation. 2001 19:2994-3018

6) Hirsh J, Raschke R. Heparin and low-molecular-weight heparin: the Seventh ACCP Conference on Antithrombotic and ThrombolyticTherapy. Chest. 2004 Sep;126(3 Suppl):188S-203S

7) Clinical and Laboratory Standards Institute (CLSI). One-Stage Prothrombin Time (PT) Test and Activated Partial ThromboplastinTime (aPTT) Test; Approved Guideline-Second Edition. CLSI Document H47-A2. (ISBN 1-56238-672-7). Clinical and LaboratoryStandards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898, USA, 2008.

D-DIMER STUDIES


● Sampling of D-dimer policies and procedures● Sampling of patient reports

LSV.39080 D-dimer Unit Results Phase I

The unit type (eg, FEU or D-DU) and unit of magnitude (eg, ng/mL) reported with thepatient results are the same units as generated directly by the D-dimer method (followingmanufacturer's product insert); or if different units are reported, the laboratory verifies thecorrect conversion of the units on an annual basis.

NOTE: The CAP and Clinical Laboratory and Standards Institute (CLSI) recommend that unitsnot be converted from those stated in the package insert. If units are converted, the laboratorymust verify the conversion of the units in patient reports for patient values, cut-off values, andreference intervals with changes in reagents, instrument and at least once per year in theabsence of a change, with records retained.

The units generated directly by the D-dimer method can be determined from the package insert.If units are not stated in the package insert, consult with the manufacturer of the D-dimer method.

The following chart demonstrates the correct conversion factor for the different reporting units:

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ManufacturerUnits

Final Units Correct ConversionFactor

Equivalency Equation

FEU ng/mL D-DU ng/mL 0.5 1 FEU ng/mL = 0.5 D-DU ng/mLFEU ng/mL D-DU µg/mL 0.0005 1 FEU ng/mL = 0.0005 D-DU µg/mLFEU µg/mL FEU ng/mL 1000 1 FEU µg/mL = 1000 FEU ng/mLD-DU ng/mL FEU ng/mL 2 1 D-DU ng/mL = 2 FEU ng/mLD-DU µg/mL FEU ng/mL 2000 1 D-DU µg/mL = 2000 FEU ng/mLD-DU µg/mL D-DU ng/mL 1000 1 D-DU µg/mL = 1000 D-DU ng/mL

Evidence of Compliance:✓ Patient reports with unit type (FEU vs. DDU) and unit of magnitude (ng/mL vs. µg/mL)

that are the same as the units directly generated by the D-dimer method and in themanufacturer's product insert OR

✓ Records of the annual verification to confirm correct conversion of the unit type (FEU vs.DDU) and unit of magnitude (ng/mL vs. µg/mL) if units are reported that are different thanthose directly generated by the D-dimer method

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Quantitative D-dimer for the Exclusion of Venous Thromboembolic Disease;

Approved Guideline. CLSI document H59-A (ISBN 1-56238-747-2). Clinical and Laboratory Standards Institute, 940 West ValleyRoad, Suite 1400, Wayne, Pennsylvania 19087 USA, 2011.

2) Olson JD, Cunninghan MT, Higgins RA, et. al. D-dimer: simple test, tough problems. 2013; 137:1030-1038

LSV.39137 D-dimer - Evaluation of VTE Phase II

If a quantitative D-dimer method is used in the evaluation of venous thromboembolism(VTE), the method is valid for this purpose.

NOTE: D-Dimer methods intended for evaluation of VTE may be used, along with pretestprobability, if a method specific cut-off value is available. Cut-off values are not universal, somethod specific data regarding the negative predictive value and the sensitivity should beavailable. For cut-off data acquired from the literature, the CLSI (H59-A) recommends a negativepredictive value of ≥98% (lower limit of CI ≥95%) and a sensitivity of ≥97% (lower limit of CI≥90%) for non-high pretest probability of VTE.

For D-dimer methods that are FDA-cleared/approved for exclusion of VTE, the package insertincludes the cut-off value and this value should be provided in the report. It is not feasible formost laboratories to perform a sufficient clinical validation of a D-dimer cut-off for use in theevaluation of VTE (ie, either exclusion or aid in diagnosis), including separate validation of thecut-off for deep vein thrombosis and pulmonary embolism. Therefore, using the cutoff suppliedfrom the manufacturer is strongly recommended.

If a laboratory or group of laboratories determine a cut-off (not published in literature or thepackage insert), a summary of data including the NPV, sensitivity, and power of determinationmust be available. The CLSI Guideline H59-A recommends correlation with imaging studiesand follow-up after three months on a minimum of 200 cases to establish the threshold for VTEexclusion.

Evidence of Compliance:✓ Package insert stating an Intended Use for the exclusion of VTE or aid in the diagnosis of

VTE AND✓ A method specific cut-off for the evaluation of VTE from the package insert, literature, or an

extensive clinical validation study

REFERENCES1) Olson J, Cunningham M, Brandt J, et al. Use of the D-Dimer for Exclusion of VTE: Difficulties Uncovered through the Proficiency

Testing Program of the College of American Pathologists (CAP). J Thromb Hemostasis, Abstract, August 20052) Spannagl M, Haverkate F, Reinauer H, Meijer P. The performance of quantitative D-dimer assays in laboratory routine. Blood Coagul

Fibrinolysis. 2005 Sep;16(6):439-433) Goodacre S, Sampson FC, Sutton AJ, et al. Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis.

QJM. 2005 Jul;98(7):513-27. Epub 2005 Jun 134) Gardiner C, Pennaneac'h C, Walford C, et al. An evaluation of rapid D-dimer assays for the exclusion of deep vein thrombosis. Br J

Haematol. 2005 Mar;128(6):842-8

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5) Diamond S, Goldweber R, Katz S. Use of D-dimer to aid in excluding deep venous thrombosis in ambulatory patients. Am J Surg.2005 Jan;189(1):23-6

6) Wolf SJ, McCubbin TR, Feldhaus KM, et al. Prospective validation of Wells Criteria in the evaluation of patients with suspectedpulmonary embolism. Ann Emerg Med. 2004 Nov;44(5):503-10

7) Gould MK. Review: of the various D-dimer assays, negative ELISA results are most useful for excluding a diagnosis of deep venousthrombosis or pulmonary embolism. ACP J Club. 2004 Nov-Dec;141(3):77

8) Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematicreview. Ann Intern Med. 2004 Apr 20;140(8):589-602

9) Clinical and Laboratory Standards Institute (CLSI). Quantitative D-dimer for the Exclusion of Venous Thromboembolic Disease;Approved Guideline. CLSI document H59-A (ISBN 1-56238-747-2). Clinical and Laboratory Standards Institute, 940 West ValleyRoad, Suite 1400, Wayne, Pennsylvania 19087 USA, 2011.

**REVISED** 09/17/2019LSV.39236 D-dimer Reporting Phase II

If a D-dimer test is used for evaluation of venous thromboembolism (VTE), the laboratoryreports the VTE exclusion cut-off value as stated by the manufacturer. If the D-dimer testis intended for other purposes (eg, DIC evaluation) a reference interval is required.

NOTE: This requirement only applies to quantitative D-dimer tests used for evaluation of VTE.

The cut-off value and upper limit of the reference interval are not always identical. The upperlimit of the reference interval may be used to evaluate disseminated intravascular coagulation(DIC), while the cut-off value is used for evaluation of VTE (see COM.29950 regarding referenceinterval reporting). The cut-off value and/or reference interval must be reported in units identicalto the patient results, including both unit type (FEU or D-DU) and unit of magnitude (eg, ng/mL).

Evidence of Compliance:✓ Patient reports including both the reference interval and the cut-off value for VTE evaluation

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Quantitative D-dimer for the Exclusion of Venous Thromboembolic Disease;

Approved Guideline. CLSI document H59-A (ISBN 1-56238-747-2). Clinical and Laboratory Standards Institute, 940 West ValleyRoad, Suite 1400, Wayne, Pennsylvania 19087 USA, 2011.

LSV.39335 Sensitivity of D-dimer Test - Evaluation of VTE Phase I

If a D-dimer test is insufficiently sensitive to exclude venous thromboembolism, thelaboratory informs clinicians that the test must not be used for this purpose.

NOTE: Manual agglutination D-dimer and FDP (fibrin degradation products) assays are notadequately sensitive for evaluation of deep vein thrombosis and/or pulmonary embolism.

FIBRINOGEN (EXCLUDING IMMUNOLOGIC METHODS)

Fibrinogen can be measured using different methodologies:● The Clauss method is a functional assay based on the time to fibrin clot formation when

excess thrombin is added to patient plasma.● The PT-derived fibrinogen assay reports a fibrinogen based on the prothrombin time.

Immunologic methods, which measure fibrinogen antigens, are covered in the Coagulation Tests Based onDirect Measurement of Analytes section.


● Sampling of fibrinogen assay policies and procedures● Sampling of patient reports● Sampling of records for standard curves and standard curve verification● Sampling of calibration/calibration verification/recalibration records

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● How do you evaluate results for inhibitor effects?

**NEW** 06/04/2020LSV.39510 Standard Curve Phase II

For end point-based fibrinogen assays, three or more points are plotted for the standardcurve.

NOTE: Plotting less than three points may generate an erroneous line.

Evidence of Compliance:✓ Written procedure for establishing standard curves AND✓ Records of standard curves for fibrinogen assays

REFERENCES1) Kitchen S, Preston FE. Assay of Factor VIII and Other Clotting Factors. In: Kitchen S, Olson JD, Preston FE, eds. Quality in

Laboratory Hemostasis and Thrombosis. 2nd ed. Hoboken, NJ: Wiley-Blackwell: 2013; chap 10.2) Clinical and Laboratory Standards Institute. Determination of Coagulant Factor Activities Using the One-State Clotting Assay;

Approved Guideline. 2nd ed. CLSI document H48-ED2. Clinical and Laboratory Standards Institute, Wayne, PA, 2016.

**NEW** 06/04/2020LSV.39520 Standard Curve Verification Phase II

The standard curves are verified with at least two reference points for each fibrinogenassay determination each eight hours of patient testing, or each time a fibrinogen assay isperformed if fibrinogen assays are performed less frequently than one per eight hours.

NOTE: The Y intercept of the standard curve varies according to the reagent and environmentalor instrument conditions. Verifying the curve (eg, two or more points with assayed referenceplasma) each time ensures accuracy of the result. If more than two standard curves exist (ie,normal concentration and low concentration curves), the CAP recommends using at least onereference point on each curve.

Evidence of Compliance:✓ Written procedure describing the verification of standard curves with two reference points

AND✓ Records of QC at defined frequency

REFERENCES1) Clinical and Laboratory Standards Institute. Determination of Coagulant Factor Activities Using the One-State Clotting Assay;

Approved Guideline. 2nd ed. CLSI document H48-ED2. Clinical and Laboratory Standards Institute, Wayne, PA, 2016.

**NEW** 06/04/2020LSV.39530 Inhibitor Effect Phase II

When fibrinogen assays are performed, the laboratory reports apparent inhibitor effects.

NOTE: The goal is to provide clinically useful data when a non-specific inhibitor activity isdetected, eg, a lupus anticoagulant or an anticoagulant drug like heparin. A comment like"inhibitor pattern detected" along with reporting the activity obtained at the highest dilution or overserial dilutions clarifies the result.

Many of the direct acting anticoagulant medications can impact the functional fibrinogen assays(eg, significant concentrations of a direct thrombin inhibitor in the Clauss method). The PT

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derived fibrinogen assay method is subject to interference by anticoagulants that effect the PTassay.

CHEMISTRY SECTION

SPECIMEN HANDLING - CHEMISTRY


● Aliquoting process. Determine if the process and procedure are adequate to preventcross-contamination and specimen mix-ups.

● What procedure does your laboratory follow when aliquots are made from the primaryspecimen?

LSV.39875 Aliquoting Phase II

There is a written aliquoting procedure to ensure prevention of cross contamination ofspecimens and aliquots.

NOTE: Certain limited volume specimens may warrant the use of previously aliquotedspecimens. In such cases, the laboratory must have a clearly defined, documented policyspecifying such circumstances and a procedure describing how it is performed.

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CALIBRATION AND VERIFICATION PROCESSES- NONWAIVED TESTS - CHEMISTRY


● Sampling of calibration and AMR policies and procedures● Sampling of calibration/calibration verification records● Sampling of AMR verification records● Sampling of patient reports and worksheets for verification of results outside of AMR

● Sampling of calibration materials (quality)


the calibration?● What is your course of action when results fall outside the AMR?● What is your course of action when you receive calibration materials for non-FDA

cleared assays?● How does your laboratory verify concentration techniques?

● Further evaluate the responses, corrective actions, and resolutions for unacceptablecalibration, and unacceptable calibration verification

The remaining requirements in this checklist on CALIBRATION, CALIBRATION VERIFICATION and ANALYTICMEASUREMENT RANGE (AMR) VERIFICATION do not apply to waived tests.

This introduction discusses the processes of calibration, calibration verification, and analytical measurementrange (AMR) verification.

CALIBRATION: The process of adjusting an instrument or test system to establish a relationship between themeasurement response and the concentration or amount of the analyte that is being measured by the testprocedure.

CALIBRATION VERIFICATION: The process of confirming that the current calibration settings for each analyteremain valid for a test system.

Each laboratory must define limits for accepting or rejecting results of the calibration verification process.Calibration verification can be accomplished in several ways. If the manufacturer provides a calibrationvalidation or verification process, it must be followed. Other techniques include (1) assay of the currentcalibration materials as unknown specimens, and (2) assay of matrix-appropriate materials with target valuesthat are specific for the method.

ANALYTICAL MEASUREMENT RANGE (AMR): The range of analyte values that a method can directlymeasure on the specimen without any dilution, concentration, or other pretreatment that is not part of the usualassay process.

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LINEARITY AND THE AMRLinearity is a fundamental characteristic of many analytic measurement methods, whereby there is a straight-line relationship between ‘‘true’’ analyte concentrations and measured concentrations. In this context, linearityrefers to the relationship between the predicted and observed measurement results and not to the relationshipbetween instrument signal output and analyte concentration. For most assays, this relationship is linear withinthe AMR.

AMR VERIFICATIONLaboratories are required to verify that the appropriate relationship is maintained over the AMR. Laboratoriesmay verify and use an AMR that is narrower than the range defined by the manufacturer. This may beappropriate when materials available for method validation and/or AMR verification are not available to verify thefull range claimed by the manufacturer, or reporting values across the full range defined by the manufacturer isnot clinically relevant. For many assays, results beyond the AMR can be reported through dilution studies (seeLSV.40652).

Minimum requirements for AMR verification can be met by using matrix appropriate materials, which includelow, mid and high concentration or activity range of the AMR with recovery of results that fall within a definedrange of the target value. Records of AMR verification must be available.

CLOSENESS OF SAMPLE CONCENTRATIONS OR ACTIVITIES TO THE UPPER AND LOWER LIMITS OFTHE AMRWhen verifying the AMR, it is required that materials used are near the upper and lower limits of the AMR.Factors to consider in verifying the AMR are the expected analytic imprecision near the limits, the clinicalimpact of errors near the limits, and the availability of test specimens near the limits. It may be difficult to obtainspecimens with values near the limits for some analytes. In such cases, reasonable procedures should beadopted based on available specimen materials. The closeness of sample concentrations or activities to theupper and lower limits of the AMR are defined at the laboratory director's discretion. The method manufacturer'sinstructions for verifying the AMR must be followed, when available. The laboratory director must define limitsfor accepting or rejecting verification tests of the AMR.

**REVISED** 09/17/2019LSV.40130 Calibration Procedure Phase II


NOTE: Calibration must be performed following manufacturer's instructions, at minimum,including the number, type, and concentration of calibration materials, frequency of calibration,and criteria for acceptable performance. Calibration procedures are typically specified in themanufacturer's instructions but may also be established by the laboratory.


amendments of 1988; final rule. Fed Register. 2003(Jan 24):3707 [42CFR493.1255]2) Department of Health and Human Services, Centers for Medicare & Medicaid Services. Medicare, Medicaid and CLIA Programs;

Laboratory Requirements Relating to Quality Systems and Certain Personnel Qualifications; Final Rule. Fed Register. 2003(Jan24):3707 [42CFR493.1255]


4) Miller WG. Quality control. In: Henry's Clinical Diagnostic and Management by Laboratory Methods, 21st Edition, , ed McPherson RA,Pincus MR. Saunders Elsevier , 2007,p 99-111

**REVISED** 09/17/2019LSV.40210 Calibration and Calibration Verification Materials Phase II


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NOTE: Calibration and calibration verification must have defined analyte target values andappropriate matrix characteristics for the clinical specimens and specific assay method. Manyinstrument systems require calibration materials with system-specific target values to produceaccurate results for clinical specimens.

Suitable materials for calibration verification include, but are not limited to:1. Calibrators used to calibrate the analytical system2. Materials provided by the manufacturer for the purpose of calibration verification3. Previously tested unaltered patient/client specimens4. Primary or secondary standards or reference materials with matrix characteristics



Evidence of Compliance:✓ Written policy defining appropriate calibration and calibration verification materials

REFERENCES1) ISO 17511:2003 In vitro diagnostic medical devices--Measurement of quantities in biological samples--Metrological traceability of

values assigned to calibrators and control materials.


Criteria are established for frequency of recalibration or calibration verification, and theacceptability of results.



2. If QC shows an unusual trend or shift or is outside acceptable limits and the systemcannot be corrected to bring control values into the acceptable range






amendments of 1988; final rule. Fed Register. 2003(Jan 24):3707[42CFR493.1255(b)(3)]2) Miller WG. Quality control, In Professional practice in clinical chemistry: a companion text, ed DR Dufour. Washington, DC: AACC

Press, 1999:12-1 to 12-22




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Verification of the analytical measurement range (AMR) is performed with matrix-appropriate materials which, at a minimum, include the low, mid and high range of theAMR, and appropriate acceptance criteria are defined.





4. Patient samples that have reference method assigned target values5. Control materials, if they adequately span the AMR and have method-specific target

values


criteria


amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1255]2) Shah VP, Midha KK, G, Dighe S, et al. Bioanalytical Method Validation - Pharm Res. 1992;9(4):588-92.

3) Hartmann C, Smeyers-Verbeke J, Massart DL, McDowall RD. Validation of bioanalytical chromatographic methods. J Pharm BiomedAnal. 1998;17(2):193-218.

4) Findlay JW et al. Analytical Methods Validation - Bioavailability, Bioequivalence and Pharmacokinetic Studies. Pharm Res.2000;17(12):1551-7.

5) Killeen AA, Long T, Souers R, Styler P, Ventura CB, Klee GG. Verifying Performance Characteristics of Quantitative AnalyticalSystems: Calibration Verification, Linearity, and Analytical Measurement Range. Arch Pathol Lab Med. 2014:138(9): 1773-81.


Verification of the analytical measurement range (AMR) is performed at least every sixmonths and following defined criteria. Records are retained.

NOTE: The AMR must be verified at least every six months after a method is initially placed inservice and if any of the following occur:

1. At changes of reagent lots unless the laboratory can demonstrate that the use ofdifferent lots does not affect the accuracy of patient/client results, and the range usedto report patient/client test data



It is not necessary to independently verify the AMR if the calibration of an assay includescalibrators that span the full range of the AMR, with low, midpoint and high values (ie, three

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points) and the system is calibrated at least every six months. A one-point or two-point calibrationdoes not include all of the necessary points to validate the AMR.

AMR verification is not required for methods that measure an analyte quantitatively or semi-quantitatively, and report a qualitative value based on concentration threshold. For suchmethods, eg, drugs of abuse, refer to checklist requirement CHM.13750.

Evidence of Compliance:✓ Written policy for AMR verification defining the frequency performed AND✓ Records of AMR verification at least every six months


amendments of 1988; final rule. Fed Register. 2003(Jan 24):3707 [42CFR493.1255]


If a result is greater than or less than the AMR, a numeric result is not reported unless thesample is processed by dilution, a mixing procedure or concentration so that the resultfalls within the AMR.


reported in routine practice. Dilution, a mixing procedure* or concentration of asample may be required to achieve a measured analyte activity or concentration thatfalls within the AMR. The result must be within the AMR before it is mathematicallycorrected by the concentration or dilution factor to obtain a reportable numeric result.


3. All dilutions, whether automatic or manual, should be performed in a way thatensures that the diluted specimen reacts similarly to the original specimen in theassay system. For some analytes, demonstrating that more than one dilution ratiosimilarly recovers the elevated concentration may be helpful.

4. This checklist requirement does not apply if the concentration or activity of theanalyte that is outside the AMR is reported as "greater than" or " less than" the limitsof the AMR.




amendments of 1988; final rule. Fed Register. 2003(Oct 1):[42CFR493.1282(b)(1)(ii)]



NOTE:1. For each analyte, the laboratory procedure defines the maximum dilution that falls

within the AMR and that can be subsequently corrected by the dilution factor toobtain a reportable numeric result. Note that for some analytes, an acceptable

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dilution procedure may not exist because dilution would alter the analyte or thematrix causing erroneous results, eg, free drugs or free hormones. Also note that,for some analytes, there may be no clinical relevance to reporting a numeric resultgreater than a stated value.

2. Analytes for which a dilution procedure is unable to bring the activity or concentrationinto the AMR should be reported as "greater than" the highest estimated values.

3. Establishment of allowable dilutions is performed when a method is first placedinto service. The laboratory director is responsible for establishing the maximumallowable dilution of samples that will yield a credible laboratory result for clinical use.


LSV.40657 Concentration Techniques Phase I

Concentration techniques for quantitative tests are verified.

NOTE: Techniques used to concentrate specimens for analysis must be verified at specified,periodic intervals (not to exceed one year or manufacturer's recommendations).

Evidence of Compliance:✓ Written procedure for verifying the accuracy of concentration techniques AND✓ Records of concentration technique verification at defined frequency

LSV.40660 Quantitative Cut-Off Values Phase I

For qualitative tests that use a quantitative cut-off value to distinguish positive fromnegative results, the analytic performance around the cut-off value is verified orestablished initially, and reverified at least every six months thereafter.

NOTE: This requirement applies to tests that report qualitative results based on a quantitativemeasurement using a threshold (cut-off value) to discriminate between positive and negativeresults for clinical interpretation. It does not apply to methods where the laboratory is not able toaccess the actual numerical value from the instrument.

Appropriate materials for establishment and verification of the cut-off are identical to thoserecommended for calibration verification. The requirement can be satisfied by the process ofcalibration or calibration verification using calibrators or calibration verification materials withvalues near the cut-off. It may also be satisfied by the use of QC materials that are near the cut-off value if those materials are claimed by the method manufacturer to be suitable for verificationof the method's calibration process.

Verification of the cut-off should also be performed at changes of lots of analytically criticalreagents (unless the laboratory director has determined that such changes do not affect the cut-off); after replacement of major instrument components; after major service to the instrument;and when QC materials reflect an unusual trend or shift or are outside of the laboratory'sacceptable limits, and other means of assessing and correcting unacceptable control values failto identify and correct the problem.

For FDA-cleared or approved tests, the clinical appropriateness of the cut-off value is evaluatedas part of the clinical validation performed by the manufacturer. For laboratory-developed testsand modified FDA-cleared or approved tests, refer to COM.40640 for validation of clinical claims.

Evidence of Compliance:✓ Written procedure for initial establishment and subsequent verification of the cut-off value

AND✓ Records of initial establishment and subsequent verification of the cut-off value at defined

frequency

REFERENCES

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1) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvementamendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1255].

2) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvementamendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1253].

LSV.40675 Neonatal Bilirubin Testing Phase II

Neonatal bilirubin results in the range of 5 to 25 mg/dL are accurate and suitable for usewith standardized clinical practice interpretive guidelines, with accuracy verified at leastannually.

NOTE: Each laboratory must assess the accuracy of its instrument/test system over the range ofbilirubin values appropriate for the clinical guidelines (5-25 mg/dL). In many cases, acceptableperformance can be verified using proficiency testing materials with assigned reference values.In other cases, the laboratory can meet the objective by using patient samples to performcorrelation studies against 1) a reference method; OR 2) an alternate method that consistentlydemonstrates good performance in a proficiency testing program (based on the method meanvalue as compared to the reference value). In all cases, such comparisons should include atleast one or two samples annually in the target clinical range of 5-25 mg/dL.

The reference method for total bilirubin is described in Doumas et al, Candidate referencemethod for determination of total bilirubin in serum: development and validation. Clin Chem,1985.

Evidence of Compliance:✓ Written assessment of adequacy for the agreement with target values in the range of the

clinical guidelines for clinical purposes, at least annually, by the laboratory director ordesignee

REFERENCES1) Lo SF, Doumas BT, Ashwood ER. Bilirubin proficiency testing using specimens containing unconjugated bilirubin and human serum:

results of a College of American Pathologists study. Arch Pathol Lab Med 2004;128:1219-12232) American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35

or more weeks of gestation. Pediatrics 2004;114:297-3163) Doumas BT, Kwok-Cheung PP, Perry BW, et al. Candidate reference method for determination of total bilirubin in serum:

development and validation. Clin Chem 1985; 31:1779-1789.4) Lo SF, Doumas BT. The status of bilirubin measurements in U.S. Laboratories: Why is accuracy elusive? Semin Perinatol 2011;

35:141-147.5) Barrington KJ, Sankaran K. Canadian Paediatric Society, Fetus and Newborn Committee. Guidelines for detection, management,

and prevention of hyperbilirubinemia in term and late preterm newborn infants. http://www.cps.ca/documents/position/hyperbilirubinemia-newborn. Accessed August 18, 2014.

CONTROLS - NONWAIVED TESTS - CHEMISTRY


● Quality control policies and procedures

LSV.40875 Calibrators and Controls Phase II

If the laboratory prepares calibrators and controls in-house, these materials are preparedseparately.

NOTE: In general, calibrators should not be used as QC materials. If calibrators are used ascontrols, then different preparations should be used for these two functions.

http://www.cps.ca/documents/position/hyperbilirubinemia-newborn

http://www.cps.ca/documents/position/hyperbilirubinemia-newborn

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Evidence of Compliance:✓ Written policy for in-house preparation of calibrators and controls

LSV.40950 Calibrators as Controls Phase I

If a calibrator obtained from an outside supplier is used as a control, it is a different lotnumber from that used to calibrate the method.

NOTE: In general, calibrators should not be used as QC materials. However, this practice maybe necessary for some methods when a separate control product is not available. In such cases,the calibrator used as a control must be from a different lot number than that used to calibrate themethod.

Evidence of Compliance:✓ Written policy for the use of calibrators as controls AND✓ QC/calibrator records


amendments of 1988; final rule. Fed Register. 2003(Jan 24):3708 [42CFR493.1256(d)(9)]

RESULTS REPORTING


● Sampling of patient toxicology reports

LSV.41335 Toxicology Results Phase II

There are written procedures for the reporting of toxicology results.

NOTE: In addition to the requirements found in the Laboratory General Checklist, the followinginformation must be included in toxicology reports:

1. If appropriate, substances or classes of substances analyzed as part of thetoxicology test

2. Specimen type3. Report status for positive results (ie, unconfirmed, confirmed or pending

confirmation)4. For immunoassays, the assay cut-off concentration for each drug*5. If the report includes unconfirmed screening results, a statement that such results

are to be used only for medical (ie, treatment) purposes. Unconfirmed screeningresults must not be used for non-medical purposes (eg, employment testing).

*The cut-off concentrations may either be included in the report or in a separate chart/memorandum available to clinicians.

Laboratories are encouraged to identify the detected drugs as parent compounds, metabolites, orimpurities of drugs in the report or in a separate chart/memorandum available to clinicians.

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GENERAL CHEMISTRY

LSV.41340 Ethanol Specificity Phase II

If the laboratory tests for ethanol, the method has been evaluated for ethanol specificity.

NOTE: Elevated lactic acid concentration and lactate dehydrogenase (LD) activity may falselyelevate enzymatically determined ethanol levels.

Evidence of Compliance:✓ Records of ethanol specificity evaluation studies OR evaluation of information provided by

the manufacturer OR evaluation of published literature

REFERENCES1) Clinical and Laboratory Standards Institute. Toxicology and Drug Testing in the Clinical Laboratory; Approved Guideline. 3rd ed. CLSI

Document C52-ED3. Clinical and Laboratory Standards Institute, Wayne, PA; 2017.2) Wu AHB, McKay C. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: Recommendations for the

Use of Laboratory Tests to Support Poisoned Patients Who Present to the Emergency Department. Clin Chem. 2003;49(3):357-379.3) Frederick DL, King DS. Lactate Dehydrogenase Can Cause False-Positive Ethanols. Clinical and Forensic Toxicology News

(Quarterly AACC/CAP). June 2012:4-7.

**NEW** 09/17/2019LSV.41341 Urine Opiates Immunoassay Cutoff Phase I

The urine opiates immunoassay cutoff is appropriate for the clinical setting.

NOTE: Opiate class immunoassays are primarily designed to detect naturally occurring opiates(eg, morphine and codeine), and have varying cross-reactivity to the semisynthetic opioids(eg, oxycodone, hydrocodone). Therefore, when utilized for clinical care, including supportof emergency departments and pain management clinics, the 300 ng/mL cutoff for the urineopiates immunoassays should be utilized. The 2000 ng/mL cutoff is more appropriate forworkplace drug testing. As a class assay, the 300 ng/mL cutoff has better detection for lowerconcentrations of naturally occurring opiates (morphine and codeine) and for the semisyntheticopioids (oxycodone, hydrocodone) when compared to the 2000 ng/mL cutoff.

It is recommended that the laboratory review the package insert for its opiates immunoassayfor cross-reactivity with the semisynthetic opioids (eg, oxycodone, hydrocodone). Specificimmunoassays for the detection of semisynthetic and synthetic (eg, buprenorphine, fentanyl)opioids are available and should be used when reliable detection of those drugs is required;alternative targeted methods such as mass spectrometry may also be appropriate.

If cutoff values different than those defined by the manufacturer are used, the laboratory mustperform appropriate validation studies to support the modification.

Evidence of Compliance:✓ Written procedure with defined cutoff appropriate for the clinical setting

REFERENCES1) Magnani BJ, Kwong TC, McMillin G, Wu AHB., eds Clinical Toxicology Testing: A Guide for Laboratory Professionals. 2nd ed.

Northfield, IL: CAP Press; 2020.

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ANTI-NUCLEAR ANTIBODY TESTING - CHEMISTRY


● Sampling of ANA result reports

**NEW** 09/17/2019LSV.41343 Anti-Nuclear Antibody Reporting Phase I

The method used for detecting anti-nuclear antibodies (ANA) is included on the report.

NOTE: Indirect immunofluorescence is traditionally used to detect antibodies with affinity forHEp-2 cells, and the pattern of ANA immunofluorescence is reported. Other methods (such asenzyme-linked immunoassay or multiplexed bead immunoassay) may not detect all of the sameautoantibodies as the HEp-2 methodology, and these differences may be clinically significant.The ANA results report must include a brief description of the method used for ANA screening ifthe methodology is not explicit in the test name.

Evidence of Compliance:✓ Records of ANA reports indicating method used

REFERENCES1) Meroni PL, Schur PH. ANA screening: an old test with new recommendations. Ann Rheum Dis. 2010; 69:1420-1422.

2) American College of Rheumatology Position Statement: Methodology of Testing for Antinuclear Antibodies. American College ofRheumatology. August 2015.

HIV PRIMARY DIAGNOSTIC TESTING - CHEMISTRY


● Sampling of HIV diagnostic testing policies and procedures● Sampling of HIV result reports

**NEW** 06/04/2020LSV.41346 HIV Primary Diagnostic Testing - Supplemental and Confirmatory Testing Phase I

The laboratory follows public health recommendations or guidelines for HIV primarydiagnostic testing, including primary screening and additional (supplemental and/orconfirmatory) testing.

NOTE: If additional testing after a primary screening test is recommended by public healthauthorities, the laboratory:

● Performs additional testing reflexively if the specimen is suitable and the test isperformed in house, or

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● Sends additional testing to a referral laboratory if the specimen is suitable, or● Provides guidance to providers on submission of additional specimens, if needed

for supplemental or confirmatory testing.

The US Centers for Disease Control and Prevention (CDC) and Association of Public HealthLaboratories (APHL) provide recommendations for HIV testing. Guidelines and recommendedalgorithms can be found on the CDC and APHL websites.

This checklist item does not apply to the testing of individuals from whom human derivedproducts for therapeutic use are being derived or other types of testing performed for themonitoring of HIV infection (eg, viral load, CD4 counts). Reporting HIV results to public health isnot within the scope of this checklist item.

Evidence of Compliance:✓ Written policy for the performance of HIV testing AND✓ Patient reports with initial screening results and reflexive testing results and/or guidance

REFERENCES1) Centers for Disease Control and Prevention and Association of Public Health Laboratories. Laboratory Testing for the Diagnosis of

HIV Infection: Updated Recommendations. Available at http://stacks.cdc.gov/view/cdc/23447. Published June 27, 2014. Accessed11/19/2019.

2) Association of Public Health Laboratories. Suggested Reporting Language for the HIV Laboratory Diagnostic Testing Algorithm.January 2019. Available at APHL Publications. Accessed 11/19/2019.

BLOOD GAS ANALYSIS

The Limited Service Laboratory Checklist is intended for inspection of laboratory sections performing testing in adedicated space. Laboratories performing testing at or near the patient bedside (eg, portable instruments) mustuse the Point-of-Care Testing Checklist.

SPECIMEN COLLECTION AND HANDLING - BLOOD GAS


● Blood gas collection policy and procedure● Sampling of records for performance of collateral circulation tests

● How are personnel that perform arterial punctures made aware of possiblecomplications?

LSV.41350 Arterial Puncture Complications Phase II

Personnel performing arterial punctures are trained in the recognition and management ofpossible complications of this procedure.

Evidence of Compliance:✓ Written records of training in personnel files

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Blood Gas and pH Analysis and Related Measurements; Approved Guideline -

Second Edition. CLSI document C46-A2 (ISBN 1-56238-694-8). Clinical and Laboratory Standards Institute, 940 West Valley Road,Suite 1400, Wayne, PA 19087-1898, USA 2009.

https://www.cdc.gov/hiv/guidelines/testing.html

https://www.aphl.org/programs/infectious_disease/Pages/HIV.aspx

http://stacks.cdc.gov/view/cdc/23447

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LSV.41370 Collateral Circulation Phase II

For radial artery sampling, a test for collateral circulation is performed before arterialpuncture, as applicable, with results recorded.

NOTE: The various technologies available have been evaluated in the published literature.Consensus should be established between the laboratory and involved clinicians to define inwhich patients and under what circumstances such a test is medically useful in averting potentialpatient injury. The site from where the sample was obtained should be recorded.

Evidence of Compliance:✓ Written collection procedure defining situations that require testing for collateral circulation to

include preferred technique(s)✓ Records of collection site and results of applicable collateral circulation testing

REFERENCES1) Vaghadia H, et al. Evaluation of a postocclusive circulatory hyperaemia (PORCH) test for the assessment of ulnar collateral

circulation. Can J Anaesth. 1988;35:591-5982) Cheng EY, et al. Evaluation of the palmar circulation by pulse oximetry. J Clin Monit. 1989;5:1-3

3) Levinsohn DG, et al. The Allen's test: analysis of four methods. J Hand Surg. 1991;16:279-282

4) Fuhrman TM, et al. Evaluation of collateral circulation of the hand. J Clin Monit. 1992;8:28-32

5) Furhman TM, et al. Evaluation of digital blood pressure, plethysmography, and the modified Allen's test as a means of evaluating thecollateral circulation to the hand. Anaesthesia. 1992;47:959-961

6) Fuhrman TM, McSweeney E. Noninvasive evaluation of the collateral circulation to the hand. Acad Emerg Med. 1995;2:195-199

7) O'Mara K, Sullivan B. A simple bedside test to identify ulnar collateral flow. Ann Intern Med. 1995;123:637

8) Starnes SL, et al. Noninvasive evaluation of hand circulation before radial artery harvest for coronary artery bypass grafting. J ThoracCardiovasc Surg. 1999;117:261-266

9) Cable DG, et al. The Allen test. Ann Thorac Surg. 1999;67:876-877

LSV.41390 Ambient Air Contamination Phase II

There is a procedure to prevent ambient air contamination of blood gas samples beforeanalysis.

Evidence of Compliance:✓ Written procedure for prevention of ambient air contamination

REFERENCES1) Ishikawa S, et al. The effects of air bubbles and time delay on blood gas analysis. Ann Allergy. 1974;33:72-77

2) Mueller RG, et al. Bubbles in samples for blood gas determinations. Am J Clin Pathol. 1976;65:242-249

3) Madiedo G, et al. Air bubbles and temperature effect on blood gas analysis. J Clin Pathol. 1980;33:864-867

4) Biswas CK, et al. Blood gas analysis: effect of air bubbles in syringe and delay in estimation. Brit Med J. 1982;284:923-927

5) McKane MH, et al. Sending blood gas specimens through pressurized transport tube systems exaggerates the error in oxygentension measurements created by the presence of air bubbles. Anesth Analg. 1995;81:179-182

6) Astles JR, et al. Pneumatic transport exacerbates interference of room air contamination in blood gas samples. Arch Pathol Lab Med.1996;120:642-647

7) Clinical and Laboratory Standards Institute (CLSI). Blood Gas and pH Analysis and Related Measurements; Approved Guideline -Second Edition. CLSI document C46-A2 (ISBN 1-56238-694-8). Clinical and Laboratory Standards Institute, 940 West Valley Road,Suite 1400, Wayne, PA 19087-1898, USA 2009.

BLOOD GAS INSTRUMENTS


● Blood Gas analysis policy and procedure● Sampling of blood gas calibration records● Sampling of blood gas QC records

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● Is any testing performed on specimen types that are not FDA-cleared/approved onthe blood gas instrument?


LSV.41490 Calibration Materials Phase II

The materials used for calibration of the pH, CO2 and O2 sensors are either inconformance with the instrument manufacturer's specifications or traceable to NISTStandard Reference Materials.

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Blood Gas and pH Analysis and Related Measurements; Approved Guideline -

Second Edition. CLSI document C46-A2 (ISBN 1-56238-694-8). Clinical and Laboratory Standards Institute, 940 West Valley Road,Suite 1400, Wayne, PA 19087-1898, USA 2009.

LSV.41570 Calibration - Blood Gas Instruments Phase II

Blood gas instruments are calibrated according to manufacturer's specifications and atleast as frequently as recommended by the manufacturer.

NOTE: Some instruments have built in calibration that is performed automatically by theinstrument; however, there must be some defined procedure for verifying the reliability of thisprocess. If appropriate, the calibration must compensate for the influence of barometric pressure.

Evidence of Compliance:✓ Written calibration procedure including defined frequency AND✓ Records for calibration at defined frequency


amendments of 1988; final rule. Fed Register. 2003(Jan 24):3709 [42CFR493.1267(a)]

LSV.41650 Daily QC-Blood Gas Instruments Phase II

A minimum of one level of quality control for pH, pCO2 and pO2 is analyzed at leastevery eight hours of operation when patient specimens are tested, or more frequently ifspecified in the manufacturer's instructions or laboratory procedure, and when changesoccur that may impact patient results.

NOTE: The laboratory must define the number and type of quality control used and the frequencyof testing in its quality control procedures. Control testing is not required on days when patienttesting is not performed. Controls must be run prior to resuming patient testing when changesoccur that may impact patient results, including after a change of analytically critical reagents,major preventive maintenance, or change of a critical instrument component, or with softwarechanges, as appropriate.

If an internal quality control process (eg, electronic/procedural/built-in) is used instead of anexternal control material to meet daily quality control requirements, the laboratory must have anindividualized quality control plan (IQCP) approved by the laboratory director to address the useof the alternative control system. Please refer to the Individualized Quality Control Plan section of

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the All Common Checklist for the eligibility of tests for IQCP and requirements for implementationand ongoing monitoring of an IQCP.

Evidence of Compliance:✓ Written quality control procedures AND✓ Records of QC results including external and internal control processes AND✓ Manufacturer product insert or manual


CLIA fee collection; correction and final rule. Fed Register. 2003(Jan 24) [42CFR493.1267(b)]2) Clinical and Laboratory Standards Institute (CLSI). Statistical Quality Control for Quantitative Measurement Procedures: Principles


LSV.41730 Daily QC-Blood Gas Instruments Phase II

The control materials for pH, pCO2 and pO2 represent both high and low values on eachday of patient testing.

NOTE: If using internal controls, the electronic simulators should challenge at high and lowvalues.

Evidence of Compliance:✓ Written procedure defining QC requirements AND✓ QC records reflecting the appropriate use of controls


CLIA fee collection; correction and final rule. Fed Register. 2003(Jan 24) [42CFR493.1267(b)]2) Clinical and Laboratory Standards Institute (CLSI). Statistical Quality Control for Quantitative Measurement Procedures: Principles


3) Ng VL, et al. The rise and fall of i-STAT point-of-care blood gas testing in an acute care hospital. Am J Clin Pathol. 2000;114:128-138

LSV.41810 QC - Blood Gas Instruments Phase II

At least one level of quality control material for pH, pCO2 and pO2 is included each timepatient specimens are tested, except for automated instruments that internally calibrate atleast once every 30 minutes of use.

NOTE: An internal quality control process (eg, electronic/procedural/built-in) may be used tomeet this requirement if an individualized quality control plan (IQCP) approved by the laboratorydirector addresses the use of the alternative control system

Evidence of Compliance:✓ Written policy defining QC requirements AND✓ QC results OR record of internal calibrator

REFERENCES1) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Fed Register. 2003(Jan 24): 3709

[42CFR493.1267(c)]2) Clinical and Laboratory Standards Institute (CLSI). Statistical Quality Control for Quantitative Measurement Procedures: Principles


HEMOGLOBIN SEPARATION

For purposes of diagnosing hemoglobinopathies, more than one test may be necessary. As an example,hemoglobin solubility testing alone is not sufficient for detecting or confirming the presence of sicklinghemoglobins in all situations. If methods other than solubility testing are performed, the Hematology andCoagulation Checklist or Chemistry and Toxicology Checklist must be used for inspection.

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● Sampling of abnormal hemoglobin policies and procedures● Sampling of patient reports (confirmatory testing, comments)● Sampling of QC records

● What is your course of action when the primary screening method appears to showHb S?

**NEW** 06/04/2020LSV.41815 Hb S Primary Screen Phase II

For samples that appear to have Hb S in the primary screening (by any method), thelaboratory either 1) performs a second procedure (solubility testing, or other acceptablemethod) to confirm the presence of Hb S, or 2) includes a comment in the patient reportrecommending that confirmatory testing be performed.

NOTE: For primary definitive diagnosis screening by electrophoresis or other separationmethods, all samples with hemoglobins migrating in the "S" positions or peak must be tested forsolubility or by other acceptable confirmatory testing for sickling hemoglobin(s). Known sicklingand non-sickling controls both must be included with each run of patient specimens tested.

Evidence of Compliance:✓ Written policy for follow-up when Hb S appears in the primary screen

COLORIMETERS, SPECTROPHOTOMETERS, AND FLUORIMETERS

The following requirements apply to stand-alone instruments; they are not applicable to instruments embeddedin automated equipment for which the manufacturer's instructions must be followed.


● Sampling of colorimeter/spectrophotometer policies and procedures● Sampling of manufacturer required system checks

● How does your laboratory verify calibration curves?

LSV.41820 Absorbance/Linearity Phase II

Absorbance and/or fluorescence linearity is checked and recorded at least annually or asoften as specified by the manufacturer, with filters or standard solutions.

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Evidence of Compliance:✓ Records of absorbance and linearity checks at required frequency

LSV.41823 Spectrophotometer Checks Phase II

Spectrophotometer (including ELISA plate readers) wavelength calibration, absorbanceand linearity are checked at least annually (or as often as specified by the manufacturer),with appropriate solutions, filters or emission line source lamps, and the results recorded.

NOTE: Some spectrophotometer designs, eg, diode array, have no moving parts that can alterwavelength accuracy and do not require routine verification. The manufacturer's instructionsshould be followed.

Evidence of Compliance:✓ Records of spectrophotometer checks at required frequency

LSV.41824 Stray Light Phase II

Stray light is checked at least annually with extinction filters or appropriate solutions, ifrequired by the manufacturer.

Evidence of Compliance:✓ Records of stray light checks, at required frequency

LSV.41825 Calibration Curves Phase II

For procedures using calibration curves, all the curves are rerun at defined intervals and/or verified after servicing or recalibration of instruments.

Evidence of Compliance:✓ Records of calibration curve rerun and/or verification at defined frequency

THERAPEUTIC DRUG MONITORING


● Sampling of TDM policies and procedures● Sampling of TDM patient reports (dosage, time of drug administration)

● How is the clinician able to link TDM laboratory results to the dosage and time thepatient received the drug?

LSV.41828 Specimen Collection/Drug Dosing Phase I

As applicable, the laboratory provides information to clinical personnel of the optimalspecimen collection time in relation to drug dosing.

Evidence of Compliance:✓ Written procedure defining criteria for specimen collection for TDM

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REFERENCES1) Nicholson PW, et al. Ideal sampling time for drug assays. Br J Clin Pharm. 1980;9:467-470

2) Howanitz PJ, Steindel SJ. Digoxin therapeutic drug monitoring practices. A College of American Pathologists Q-Probes study of 666institutions and 18679 toxic levels. Arch Pathol Lab Med. 1993;117:684-690

3) Schoenenberge RA, et al. Appropriateness of antiepileptic drug level monitoring. JAMA. 1995;274:1622-1626

4) Williamson KM, et al. Digoxin toxicity: an evaluation in current clinical practice. Arch Intern Med. 1998;158:2444-2499

LSV.41834 TDM Results Phase II

Where applicable, TDM results are reported in relation to patient dosing and/or timinginformation.

NOTE: The intent is to have a mechanism whereby the clinician can easily and accurately linkTDM results from the laboratory to the dosage and time of drug administration. Ideally, the testresults, dose and administration time would be reported in juxtaposition on the patient chart.This may be the responsibility of the laboratory, or an integrating function of reported laboratoryanalytic data with clinical information from other sources.

Evidence of Compliance:✓ Written procedure defining criteria for reporting TDM results

REFERENCES1) Elin RJ. Computer-assisted therapeutic drug monitoring. Clin Lab Med. 1987;7:485-492

2) Howanitz PJ, Steindel SJ. Digoxin therapeutic drug monitoring practices. A College of American Pathologists Q-Probes study of 666institutions and 18679 toxic levels. Arch Pathol Lab Med. 1993;117:684-690

3) Schoenenberge RA, et al. Appropriateness of antiepileptic drug level monitoring. JAMA. 1995;274:1622-1626

4) Williamson KM, et al. Digoxin toxicity: an evaluation in current clinical practice. Arch Intern Med. 1998;158:2444-2499

5) Steele BW, et al. An evaluation of analytic goals for assays of drugs. A College of American Pathologists therapeutic drug monitoringsurvey study. Arch Pathol Lab Med. 2001;125:729-735

LSV.41838 Immunosuppressive Drug Result Reporting Phase II

For the reporting of immunosuppressive drug results, the patient report contains all of thefollowing:

1. Appropriate therapeutic ranges based on the test method used2. Analytical method (all tests) and method platform (immunoassays only)3. Elements required in GEN.41096

NOTE: For immunosuppressive drugs (eg, cyclosporine, sirolimus, tacrolimus, mycophenolicacid, everolimus), the therapeutic range may depend upon the test method, type of transplant,and length of time since the transplant procedure. Results from different types of samples anddifferent methods are not interchangeable.

Evidence of Compliance:✓ Written procedure for reporting immunosuppressive drug results AND✓ Patient results showing required report elements

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URINALYSIS AND CLINICAL MICROSCOPY SECTION

SPECIMEN COLLECTION AND HANDLING - URINALYSIS


● Sampling of urinalysis specimen collection and handling policies and procedures

● Urine collection instructions for patients

● What is your course of action when you receive unacceptable urine specimens?

**REVISED** 06/04/2020LSV.42050 Urine Specimen Collection Phase II

Instructions are provided to patients for the proper collection of clean voided urinespecimens (ie, in nursing procedure manual or in specimen collection area).

NOTE: Proper collection of urine specimens is important to avoid contamination, or deteriorationof constituents. Instructions must be available to all personnel that collect urine specimens tooutline proper specimen collection. While not required, the CAP suggests having instructions inforeign languages common to the population served by the laboratory.

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Urinalysis; Approved Guideline - Third Edition. CLSI Document GP16-A3. (ISBN

1-56238-687-5). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898, USA, 2009.

**REVISED** 06/04/2020LSV.42290 Urine Specimen Examination Phase II

Urine specimens without chemical preservative or refrigeration are examined within twohours of collection.

Evidence of Compliance:✓ Written procedure defining criteria for urine specimen handling AND✓ Records of time of collection and examination

REFERENCES1) Haber MH. Quality assurance in urinalysis. Clinics in Lab Med. 1998;8:432-436

2) Clinical and Laboratory Standards Institute (CLSI). Urinalysis; Approved Guideline - Third Edition. CLSI Document GP16-A3. (ISBN1-56238-687-5). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898, USA, 2009.

3) Howanitz PJ, et al. Timeliness of urinalysis. A College of American Pathologists Q-Probes study of 346 small hospitals. Arch PatholLab Med. 1997;121:667-672

4) Semeniuk H, et al. Evaluation of the leukocyte esterase and nitrite urine dipstick screening tests for detection of bacteriuria in womenwith suspected uncomplicated urinary tract infections. J Clin Microbiol. 1999;37:3051-3052

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**REVISED** 06/04/2020LSV.42370 Urine Preservation Phase II

There is a written procedure defining the method for urine preservation (refrigeration orspecified preservative) within the laboratory for all tests when analysis is to be delayed.

NOTE: If testing is unavoidably delayed (night collection, etc.), the laboratory must define themethod for appropriate preservation of specimens to maintain integrity of cells and formedelements.

● Refrigeration of urine may be acceptable because it inhibits bacterial growth;however, it does not prevent the lytic effects of low specific gravity or alkaline pHand may induce urine crystal formation.

● Preparations that contain boric acid/sorbitol or release formaldehyde may beeffective preservatives for some, but not all, urine tests. If preservatives areused, the procedure must include instructions to indicate which preservativewas added. In addition, the testing procedure must also identify any pre-analyticerrors attributable to such preservatives.

Evidence of Compliance:✓ Written procedure for urine specimen preservation

REFERENCES1) Delanghe JR, Speeckaert MM. Preanalytics in urinalysis. Clin Biochem. 2016;49(18):1346-50.

2) Clinical and Laboratory Standards Institute (CLSI). Urinalysis; Approved Guideline - Third Edition. CLSI Document GP16-A3. (ISBN1-56238-687-5). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898, USA, 2009.

3) Howanitz PJ, et al. Timeliness of urinalysis. A College of American Pathologists Q-Probes study of 346 small hospitals. Arch PatholLab Med. 1997;121:667-672

CALIBRATION AND STANDARDS - NONWAIVED TESTS - URINALYSIS

NOTE: Explanatory notes for calibration are found in the Chemistry section of the Limited Service LaboratoryChecklist. The master version of the checklist may be downloaded using e-LAB Solutions on the CAP website.


● Sampling of calibration policies and procedures● Sampling of calibration/calibration verification records

● What is your course of action when calibration is unacceptable?● When was the last time you performed a calibration procedure and how did you verify

the calibration?● How do you verify the function of the refractometer?

● Further evaluate the responses, corrective actions and resolutions for unacceptablecalibration results


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NOTE: Calibration is the process of adjusting an instrument or test system to establish arelationship between the measurement response and the concentration or amount of an analytethat is being measured by the test procedure.

Calibration must be performed following manufacturer's instructions, at minimum, including thenumber, type, and concentration of calibration materials, frequency of calibration, and criteria foracceptable performance.


amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1255]

**REVISED** 09/17/2019LSV.42380 Calibration/Calibration Verification Criteria Phase II

Criteria are established for frequency of calibration or calibration verification, and theacceptability of results.



2. If QC shows an unusual trend or shift or is outside of acceptable limits, and thesystem cannot be corrected to bring control values into the acceptable range

3. After major maintenance or service4. When recommended by the manufacturer

Evidence of Compliance:✓ Written procedure defining the method, frequency and limits of acceptability of calibration



amendments of 1988; final rule. Fed Register. 2003(Jan 24):7165 [42CFR493.1255]2) Miller WG. Quality control. In: Henry's Clinical Diagnostic and Management by Laboratory Methods, 21st Edition, ed McPherson RA,

Pincus MR, Saunders Elsevier, 2007:99-111.






LSV.42450 Refractometer Calibration Check Phase I

Refractometers with specific gravity capability are checked at least annually withappropriate solutions of known specific gravity and/or refractive concentration index.

NOTE: This annual calibration check is required in addition to the daily QC requirement for non-waived testing.

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REFERENCES1) Haber MH. Quality assurance in urinalysis. Clinics in Lab Med. 1988;8:432-436

2) Clinical and Laboratory Standards Institute. Laboratory Instrument Implementation, Verification, and Maintenance; ApprovedGuideline. CLSI Document GP31-A. Clinical and Laboratory Standards Institute, Wayne, PA, 2009.

PROCEDURES AND TEST SYSTEMS

The elements of a macroscopic urinalysis vary according to the patient population served by a laboratory andthe needs of clinicians. A complete routine urinalysis should include at least the following: glucose, protein,blood/hemoglobin, leukocyte esterase, specific gravity, and nitrite. Other analytes (eg, color, clarity, turbidity,bilirubin, ketones, pH and urobilinogen) are optional for CAP accreditation, but their utility should be reviewedwith the medical staff served by the laboratory. There are few occasions when the color, clarity and odor of urineare of clinical significance.


● Sampling of urinalysis policies and procedures● Sampling of patient reports with appropriate reportable parameters

LSV.42650 Microscopic Exam Correlation Phase II

There is a written procedure for correlation of microscopic sediment findings (such ascasts, RBC, or WBC) with macroscopic results (presence of protein, positive occult blood,positive leukocyte esterase, etc.).

REFERENCES1) van Nostrand JD, et al. Poor predictive ability of urinalysis and microscopic examination to detect urinary tract infection. Am J Clin

Pathol. 2000;113:709-7132) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvement

amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1281(b)]

LSV.43090 Microscopic Exam Phase II

Microscopic examination of urine sediment is performed as part of complete urinalysistesting, or there are specific, written criteria defining the circumstances under which themicroscopic examination may be omitted/abbreviated.

NOTE: There is evidence that in random urinalysis screening (hospital admissions, insurancephysicals), urines that are yellow and clear and have negative chemical reactions have amarkedly low yield on microscopic examination. Optimal service may entail protocols definingwhen microscopic examination of urine sediment should or should not be done.

Evidence of Compliance:✓ Written procedure defining criteria for performance of manual microscopic examinations AND✓ Patient reports with microscopic results OR records reflecting procedure for abbreviated

testing

REFERENCES1) Wenz B, Lampasso JA. Eliminating unnecessary urine microscopy. Results and performance characteristics of an algorithm based

on chemical reagent strip testing. Am J Clin Pathol. 1989;92:78-812) Schumann GB, Friedman SK. Comparing slide systems for microscopic urinalysis. Lab Med. 1996;27:270-277

3) Hooper DW. Detecting GD and preeclampsia: effectiveness of routine urine screening for glucose and protein. J Reprod Med.1996;41:885-888

4) Jou WW, Powers RD. Utility of dipstick analysis as a guide to management of adults with suspected infection or hematuria. SouthMed J. 1998;91:266-269

5) van Nostrand JD, et al. Poor predictive ability of urinalysis and microscopic examination to detect urinary tract infection. Am J ClinPathol. 2000;113:709-713

6) Ringsrud KM. Cells in the urine sediment. Lab Med. 2001;32:153-155

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7) Roggeman S, Zaman Z. Safely reducing manual urine microscopy analyses by combining urine flow cytometer and strip results. AmJ Clin Pathol. 2001;116:872-878

8) Clinical and Laboratory Standards Institute. Physician and Nonphysician Provider-Performed Microscopy Testing; ApprovedGuideline 2nd ed. CLSI document POCT10-A2. Clinical and Laboratory Standards Institute, Wayne, PA, 2011.

URINALYSIS - MANUAL MICROSCOPY


● Sampling of urinalysis policies and procedures● Sampling of records of morphologic observation consistency evaluation

● Reference materials (atlas, photomicrograph, chart available)

● How does your laboratory ensure consistency among personnel performing urinesediment morphology?

LSV.43130 Azoospermic Specimen Result Reporting Phase I

For azoospermic and post-vasectomy seminal fluid specimens, the laboratory clearlycommunicates the findings of the assay and either employs a concentrating technique onseminal fluid or includes a comment in the patient report indicating that a concentratingtechnique was not performed.

NOTE: Without a concentration technique, the presence of both motile and non-motile spermmay not be detected. The method for detection of motile and non-motile sperm and thelaboratory findings must be clearly communicated on the patient report so that the clinician caninterpret the results in context to the method performed. The decision on the method used andextent of testing to be performed should be made in consultation with the medical staff served.

The American Urological Association (AUA) Vasectomy Guideline recommends a carefulevaluation of an uncentrifuged specimen and does not recommend centrifugation of thespecimen for further assessment. The AUA Guideline also recommends reporting both thepresence and absence of sperm and presence or absence of sperm motility on the patient report.If no sperm are seen in the uncentrifuged specimen, the guideline recommends reporting that thepresence of sperm is below the limit of detection.

Evidence of Compliance:✓ Patient report with concentration findings or appropriate comment indicating that

concentration was not performed

REFERENCES1) Evaluation of the Azoospermic Male. Fertil Steril. 2008; 90 (S74-7)

2) Diagnostic Evaluation of the Infertile Male: A Committee Opinion. Fertil Steril. 2012; 98:294-301

3) American Urological Association (AUA) Guideline. American Urological Association Education and Research, Inc. 2012; amended2015. https://www.auanet.org/guidelines/vasectomy-(2012-amended-2015)

4) Vasectomy Update 2010. Can Urol Assoc J. 2012 October; 4(5):306-309

https://www.auanet.org/guidelines/vasectomy-(2012-amended-2015)

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LSV.43170 Reference Materials Phase I

Reference materials (atlases, charts or photomicrographs) are available to assist in themicroscopic identification of sediment constituents.

REFERENCES1) Haber MH, Blomberg D, Galagan K, Glassy EF, Ward PCJ. Color Atlas of the Urinary Sediment: An Illustrated Field Guide Based on

Proficiency Testing. Northfield, IL: College of American Pathologists; 2010.2) Etzell JE, Bradley KT, Keren DF, et al. Urinalysis Benchtop Reference Guide: An Illustrated Guide for Cell Morphology. Northfield, IL:

College of American Pathologists; 2014.3) Graff L. A handbook of routine urinalysis. Philadelphia, PA: JB Lippincott, 1983

4) Brunzel NA. Fundamentals of urine and body fluid analysis.3rd ed. Philadelphia, PA: Elsevier Health Sciences, 20125) King C. Comparison of methods for detecting indinavir crystals in urine. Am J Clin Pathol. 1998;110:540

6) Hortin GL, et al. Detection of indinavir crystals in urine. Dependence on method of analysis. Arch Pathol Lab Med. 2000;124:246-250

**REVISED** 09/17/2019LSV.43250 Morphologic Observation Evaluation Phase II

The laboratory evaluates consistency of morphologic observation among personnelperforming urine sediment microscopy at least annually.

NOTE: The laboratory must ensure the identification of urine sediment constituents is reportedconsistently amongst all personnel performing the microscopic analysis.


1. Circulation of a pre-graded set of preserved urine sediments with definedabnormalities involving leukocytes, erythrocytes, casts, bacteria, yeast, etc.

2. Multi-headed microscopy3. Use of urine sediment photomicrographs with referee and consensus identifications

(eg, former CAP surveys clinical microscopy photomicrographs)4. Digital images


Evidence of Compliance:✓ Written policy defining the method and criteria used for evaluation of consistency AND✓ Records of evaluation

REFERENCES1) Haber MH, Blomberg D, Galagan K, Glassy EF, Ward PCJ. Color Atlas of the Urinary Sediment: An Illustrated Field Guide Based on

Proficiency Testing. Northfield, IL: College of American Pathologists; 2010.2) Etzell JE, Bradley KT, Keren DF, et al. Urinalysis Benchtop Reference Guide: An Illustrated Guide for Cell Morphology. Northfield, IL:

College of American Pathologists; 2014.3) Astion ML, et al. A web-based system for assessing competency is microscopic urinalysis. Clin Chem. 2000;46:A36

4) Kim A, et al. Web-based competency assessment system for microscopic urinalysis. Clin Chem. 2002;48:1608-1611

AUTOMATED AND SEMI-AUTOMATED SYSTEMS

DIPSTICK READERS


● Sampling of urinalysis policies and procedures● New dipstick reader comparison study with previous manual or automated method, if

applicable

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● How did your laboratory perform the current dipstick instrument comparison study?

LSV.43650 Dipstick Reader Phase I

There are criteria for identifying urine samples that may give erroneous results by thedipstick reader and thus require evaluation by alternate means (visual examination orother confirmatory method).

NOTE: Criteria should be given for identifying urine samples that may give erroneous results bythe dipstick reader, and thus require confirmation by other means, such as visual examination.Intensely colored urine samples may result in false positive dipstick reactions with automatedreflectance readers. However, the anomalous color will be apparent when visual evaluation isperformed.

REFERENCES1) De Buys Roessingh AS, et al. Dipstick measurements of urine specific gravity are unreliable. Arch Dis Child. 2001;85:155-157

AUTOMATED MICROSCOPY SYSTEMS


● Sampling of urinalysis policies and procedures● Sampling of automated microscopy QC results, if applicable

● How did your laboratory establish reportable range limits for your instrument?

LSV.43656 Erroneous Morphology Results Phase II

Based on any limitations detected in the initial evaluation, criteria are established foridentifying urine specimens that may give clinically relevant erroneous results.

NOTE: Excessively turbid urine samples may block aperture flow or interfere with visual detectionof pertinent microscopic elements. Manual microscopic examination should be performed ifproblems are noted with accurate identification or classification or clinically important urinestructures, such as casts.

REFERENCES1) Elin RJ, et al. Comparison of automated and manual methods for urinalysis. Am J Clin Pathol. 1986;86:731-737

2) Wargotz ES, et al. Urine sediment analysis by the Yellow Iris automated urinalysis workstation. Am J Clin Pathol. 1987;88:746-748

3) Carlson DA, Statland BE. Automated urinalysis, In Haber MH, Corwin HL (eds). Urinalysis. Clinics in Lab Med. 1988;8:449-461

LSV.43657 Carryover Detection Phase II

There is a written procedure for detection and evaluation of potential carryover for theautomated microscopy system.

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NOTE: Carryover studies must be performed as part of the initial evaluation of an instrument.Carryover studies should be repeated after major maintenance or repair of the pipettingassembly of the instrument.

If carryover is detected or cannot be evaluated (eg, spermatozoa), the written procedure mustinclude criteria for identifying results that may be affected and define actions to be taken toprevent the release of incorrect results (eg, run blank samples after a turbid or bloody sample,reflex to manual microscopic review).

Evidence of Compliance:✓ Records of reassessment of samples with potential carryover

REFERENCES1) Clinical and Laboratory Standards Institute. Laboratory Instrument Implementation, Verification, and Maintenance; Approved

Guideline. CLSI Document GP31-A. Clinical and Laboratory Standards Institute, Wayne, PA; 2009.2) Clinical and Laboratory Standards Institute. Preliminary Evaluation of Quantitative Clinical Laboratory Methods; Approved Guideline.

3rd ed. CLSI Document EP10-A3-AMD. Clinical and Laboratory Standards Institute, Wayne, PA; 2014.

LSV.43659 Daily QC - Automated Microscopy Systems Phase II

Controls at two different levels are run each day of patient testing on automatedmicroscopy systems used for microscopic urinalysis.

NOTE: Controls must be analyzed no less frequently than each day of patient testing to detectinstrument malfunction. Accumulation of sediment can block the flow aperture, leading tospuriously low counts.

Evidence of Compliance:✓ Records of daily QC results


Upper and lower limits of all quantitative reportable parameters on automated microscopysystems are defined, and results that fall outside these limits are reported properly.

NOTE: The laboratory must initially establish or verify the reportable range for each parameterof its automated microscopy system. Apparent counts that are lower or higher than thereportable range may be reported as "less than" the lower limit or "greater than" the higher limit.Alternatively, when clinically appropriate, samples with results exceeding the higher limit may bediluted so that the value falls within the established analytic range, and appropriate multipliersapplied.

Evidence of Compliance:✓ Written policy defining the upper and lower instrument reporting limits AND✓ Record of action taken when limits are exceeded, including the reporting of results



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BODY FLUIDS SECTIONInspector Instructions:

● Sampling of manual or automated body fluid policies and procedures● Sampling of patient reports● Sampling of QC records

● Counting chamber condition● Body fluid smear (uniquely identified, uniform cell distribution, appropriate dilution so

cells are not crowded, properly stained, adequate cell yield, ready recognition of celltypes that are reported)


● How do you ensure that morphologic observations are consistent among allpersonnel who report body fluid cell differential results?

● What do you do if you suspect malignant or unusual cells on the body fluid smear?

MANUAL CELL COUNT - BODY FLUID

LSV.43662 Diluting Equipment Phase II

Certified pipettes or commercial dilution systems are used when diluting body fluidsamples.

LSV.43668 Background Checks - Manual Counts Phase II

The diluting fluid is checked for non-specimen background particulates and changedwhen indicated.

NOTE: Checking can be done by examining samples of these fluids under the microscope.The check must be performed each day of use for manual diluting methods. If commercialmicrodilution systems are used, daily checks are not required but each lot must be examinedvisually for uniformity of filling and clarity. If diluting fluids are prepared by the laboratory, theymust be prepared aseptically; refrigeration is recommended to prevent contamination withmicroorganisms.

Evidence of Compliance:✓ Written procedure defining frequency and method for performing background checks AND✓ Records of background checks

LSV.43670 Manual Cell Count Controls Phase II

For manual body fluid cell counts, at least one cell count control specimen is analyzed induplicate, or a procedural control used, for each eight hours of patient testing.

NOTE: This requirement can be met with assayed liquid control material, a previously assayedpatient sample, or a procedural control. An example of a procedural control is correlation of the

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cell count with the cellularity of a stained slide prepared by a standard, validated method. Liquidcontrol materials must be tested in duplicate.

Evidence of Compliance:✓ Written procedure for quality control of manual body fluid cell counts AND✓ Records of cell count or procedural controls at defined frequency


amendments of 1988; final rule. Fed Register. 2004(Oct 1):1041 [42CFR493.1269(a)

LSV.43671 Counting Chamber and Optical Grid Quality Phase I

The lines in all counting or motility chambers, ocular micrometers, and optical grids arebright and free from scratches, dirt, or debris.

LSV.43674 Body Fluid Analysis Procedure Phase II

For manual body fluid cell counts, each sample is counted in duplicate.

NOTE: Testing records must reflect the performance of the counts in duplicate for all countingchambers. Limits of agreement between replicate counts must be defined.

Evidence of Compliance:✓ Written procedure requiring duplicate counts to include limits of agreement AND✓ Records or worksheets reflecting duplicate counts and corrective action when limits of

agreement are exceeded



LSV.43680 Cell Clumps/Debris - Manual Methods Phase II

The laboratory indicates (as part of the report) that results may be inaccurate if the fluidspecimen is partially clotted or has cell clumps or debris on the counting chamber.

LSV.43692 Red Cell Confirmation Techniques Phase I

There is an additional procedure beyond unstained bright-field microscopic visualizationof cells on the hemocytometer used when necessary to ensure the accurate distinction oferythrocytes from other cell types.

NOTE: Suggested techniques include acid rinsing of the fluid sample to lyse erythrocytes afterinitially counting all cells, the addition of a stain such as methylene blue to improve recognition ofnon-erythrocytes, correlation with the number and proportion of cells on the cytospin preparationor phase microscopy.

Evidence of Compliance:✓ Written procedure defining laboratory's confirmation method when leukocyte results are

reported AND✓ Records of confirmation testing

AUTOMATED CELL COUNT - BODY FLUID

LSV.43698 Background Checks - Automated Counts Phase II

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Instrument background counts are performed each day of testing on the diluent fluid andlysing agent to check for contamination that might affect cell counts.

NOTE: This can be done by processing these fluids on the instrument used for cell counting andchecking for the presence of significant background in the diluting fluids and lysing agents.

Evidence of Compliance:✓ Written procedure defining frequency and method for performing background checks AND✓ Records of background checks

LSV.43710 Acceptable Limits Phase II

The laboratory has defined the upper and lower limits for counting body fluid cells(erythrocytes, nucleated cells) outside of which the use of automated or semi-automatedcell counters is not reliable.

NOTE: The laboratory must have an appropriate protocol which limits the use of automated orsemi-automated instruments for cell counting in the very low concentration ranges often seenwith body fluids. The lower limit selected must reflect the particular instrument's backgroundcount and sensitivity.

Evidence of Compliance:✓ Written policy defining the upper and lower reporting limits for automated and/or semi-

automated cell counters and actions to be taken if the limits are exceeded AND✓ Records of study to validate reportable range

REFERENCES1) International Committee for Standardization in Haematology (ICSH). Protocol for evaluation of automated blood cell counters. Clin

Lab Haemat. 1984;6:69-842) Subira D, et al. Flow cytometric analysis of cerebrospinal fluid samples and its usefulness in routine clinical practice. Am J Clin

Pathol. 2002;117:952-958

LSV.43716 Cell Clumps/Debris - Automated Counts Phase II

The laboratory has a procedure to detect clumps of cells or debris that may give spuriouscell counts.

NOTE: The procedure should include performing macroscopic assessment of body fluid samplesprocessed on cell counting instruments. Instrument generated flags and findings on microscopicexamination that suggest the presence of debris are important observations and may requirethe performance of a wet mount. Marked clumping or clots precludes reporting an automatedcount. The laboratory report should note the limited accuracy of cell counts in these situations,and include a description of the specimen problem.

LSV.43722 Stabilized Controls Phase II

Two different stabilized control specimens are analyzed each day of testing with resultsrecorded and reviewed for acceptability.

NOTE: Manufacturers recommendations for control material selection should be followed, andthe selected control should be compatible with the methodology used by the instrument.

NUCLEATED CELL DIFFERENTIALS - BODY FLUID

LSV.43734 Quantitative Differentials Phase I

The method for differentiating body fluid cells is appropriate for the intended clinical use.

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NOTE: The laboratory should use stained cytocentrifuge preparations to facilitate quantitativedifferentials and complete classification of nucleated cell types in body fluids, as opposedto performing differentials of unstained hemocytometer preparations. Differentials basedon supravitally-stained hemocytometer preparations, wedge smears and drop preparationsare considered suboptimal; their use should be limited to clinical circumstances requiringdifferentiation of polymorphonuclear from mononuclear cells (eg, bacterial meningitis). Furthersub-classification of nucleated cells, particularly the detection of malignant cells, should beperformed using slide preparation methods that provide optimal cell recovery and morphologicdetail, such as cytocentrifugation. Cytocentrifuge preparations provide excellent morphologicdetail, deliver a high yield of cells even when the concentration is low, and have a high rate ofdetection for malignant cells. In cases of leukemia or lymphoma, Romanowsky-stained cytospinslides show excellent morphologic correlation with blood and bone marrow smears. If thelaboratory uses an alternate slide preparation method or stain for sub-classification of body fluidmononuclear cells and/or detection of malignant cells, it must demonstrate from literature or in-house studies that this technique is equivalent in cell yield/recovery and morphologic detail toRomanowsky-stained cytocentrifuge preparations.

Evidence of Compliance:✓ Written procedure defining method for performing cell differentiation on body fluid, AND✓ Records showing in-house or literature validation of techniques other than Romanowsky-

stained cytocentrifuge preparations

REFERENCES1) Mengel M. The use of the cytocentrifuge in the diagnosis of meningitis. Am J Clin Pathol. 1985;84:212-216

2) Ricevuti G, et al. Meningeal leukemia diagnosed by cytocentrifuge study of cerebrospinal fluid. Arch Neurol. 1986;43:466-470

3) Davey DD, et al. Millipore filter vs cytocentrifuge for detection of childhood central nervous system leukemia. Arch Pathol Lab Med.1986;110:705-708

4) Clare N, Rone R. Detection of malignancy in body fluids. Lab Med. 1986;17:147-150

5) Odom LF, et al. Significance of blasts in lowcell cerebrospinal specimens from children with acute lymphoblastic leukemia. Cancer.1990;66:1748-1754

6) Craver RD, Carson TH. Hematopoietic elements in cerebrospinal fluid in children. Am J Clin Pathol. 1991;95:532-535

7) Rippin KP, et al. Clinical evaluation of the slide centrifuge (cytospin) gram's stained smear for the detection of bacteriuria andcomparison with the Filtracheck-UTI and UTIscreen. Am J Clin Pathol. 1995;103:316-319

8) Jones CD, Cornbleet PJ. Wright-Giemsa cytology of body fluids. Techniques for optimal cytocentrifuge slide preparation. Lab Med.1997;28:713-716

9) Kleine TO, Lehmitz R. Evaluation of cytodiagnosis of cerebrospinal fluid (CSF) cells. Clin Chem. 2000;46:A137

LSV.43740 Body Fluid Smear Quality Phase I

The quality of body fluid smears is satisfactory (uniform cell distribution, appropriatedilution so cells are not crowded, properly stained, adequate cell yield, ready recognitionof cell types that are reported).

REFERENCES1) Jones CD, Cornbleet PJ. Wright-Giemsa cytology of body fluids. Techniques for optimal cytocentrifuge slide preparation. Lab Med.

1997;28:713-716

**REVISED** 09/17/2019LSV.43746 Morphologic Observation Evaluation - Body Fluid Phase II

The laboratory evaluates consistency of morphologic observation among personnelperforming body fluid cell differentials at least annually.

NOTE: The laboratory must ensure the identification of body fluid cells is reported consistentlyamongst all personnel performing the microscopic analysis.


1. Circulation of a pre-graded set of body fluid smears with defined nucleated celldifferential distributions

2. Multi-headed microscopy

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3. Use of body fluid photomicrographs with referee and consensus identifications (eg,former CAP Surveys photomicrographs)

4. Use of digital images



REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Body Fluid Analysis for Cellular Composition; Approved Guideline. CLSI

document H56-A (ISBN 1-56238-614-X). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne,Pennsylvania 19087-1898 USA, 2006.

LSV.43752 Slide Review Phase II

Slides with suspected malignant cells are reviewed by a pathologist or other qualifiedphysician before final results reporting.

Evidence of Compliance:✓ Written policy defining criteria for slide review by pathologist/physician AND✓ Records of slide review

LSV.43758 Microscopic Result Comparison Phase I

If a body fluid specimen has a microscopic examination in more than one area of thelaboratory, there is a mechanism to compare the data and interpretations from thesedifferent areas when a diagnosis of malignancy is suspected.

Evidence of Compliance:✓ Written procedure for comparing microscopic results performed in multiple laboratory

sections when malignancy is suspected AND✓ Records of comparison

REFERENCES1) Clare N, Rone R. Detection of malignancy in body fluids. Lab Med. 1986;17:147150

2) Walts AE, Strigle S. Toward optimal use of the cytology laboratory: quality improvement and cerebrospinal fluid specimens. DiagnCytopathol. 1995;13:357-361

3) Clinical and Laboratory Standards Institute (CLSI). Body Fluid Analysis for Cellular Composition; Approved Guideline. CLSIdocument H56-A (ISBN 1-56238-614-X). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne,Pennsylvania 19087-1898 USA, 2006.

LSV.43764 Cytomorphology Reference Library Phase I

There is a file of unusual slides and/or an atlas of body fluid cytomorphology readilyavailable to the technologist evaluating the slides, to assist in the identification of celltypes.

REFERENCES1) Etzell JE, Clarke MR, Girgis G, et al; College of American Pathologists Hematology and Clinical Microscopy Resource Committee.

Body Fluids Benchtop Reference Guide: An Illustrated Guide for Cell Morphology. Northfield, IL. College of American Pathologists;2013.

2) Kolmer HW. Atlas of cerebrospinal fluid cells, 2nd ed. New York, NY: Springer-Verlag, 1977

3) Dieppe PA, et al. Synovial fluid crystals. Quart J Med. 1979;192:533-553

4) Glasser L. Body fluids II. Reading the signs in synovia. Diag Med. 1980;3(6):35-50

5) Glasser L. Body fluids III. Tapping the wealth of information in CSF. Diag Med. 1981;4:23-33

6) Greening SE, et al. Differential diagnosis in effusion cytology. J Med Tech. 1984;1:885-895

7) Strasinger SK. Urinalysis and body fluids. A self instructional text. Philadelphia: FA Davis, 1985:134-186

8) Hyun BH, Salazar GH. Cerebrospinal fluid cells in leukemias, lymphomas, and myeloma. Lab Med. 1985;16: 667-670

9) Kjeldsberg CR, Knight JA. Body fluids, 3rd ed. Chicago, IL: American Society of Clinical Pathology, 1993

10) Galagan KA, Blomberg D, Cornbleet PJ, Glassy EF, Color Atlas of Body Fluids, CAP, 2006.

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LSV.43770 Slide Retention Phase I

Slides are retained for future reference.

NOTE: All body fluid smears must be retained for at least one week for possible review/reference. The laboratory may choose to retain significantly abnormal smears (eg, thosedemonstrating microorganisms, cytologically suspicious or overtly malignant cells, etc.) for longerperiods to allow for review as part of the laboratory's correlative or quality assurance programs ordelayed clinical queries, as defined in the laboratory's slide retention policy. If a longer retentionperiod is defined, it must be followed.

SEMEN ANALYSIS

The preceding requirements in the Body Fluid Cell Counting and Body Fluid Nucleated Cell Differentialssections are generally applicable to semen analysis. Additional items of importance to this specialized area areidentified in this section.


● Sampling of manual and automated semen analysis policies and procedures● Sampling of specimen collection and handling policies and procedures● Sampling of patient records for all necessary collection information● Patient instructions● Sampling of stain QC records● Sampling of patient reports● Sampling of calibration/calibration verification records● Sampling of QC records

● Stained smear (properly stained, free of precipitate, uniform cell distribution,recognition of reportable cell types)


● What do you do if there is difficulty distinguishing leukocytes from other round cellswhen performing sperm counts using bright field microscopy?

● How is the sperm motility method in use verified?● How do you ensure that morphologic observations are consistent among all

personnel who report sperm differential results?● What is your course of action when the concentration of the specimen is outside of

the instrument measurement range?

● Follow a semen analysis from requisition, collection information, testing, reporting andrecording of results. Determine if practice follows laboratory procedure.

LSV.43773 Azoospermic Specimen Result Reporting Phase I

For azoospermic and post-vasectomy seminal fluid specimens, the laboratory clearlycommunicates the findings of the assay and either employs a concentrating technique on

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seminal fluid or includes a comment in the patient report indicating that a concentratingtechnique was not performed.

NOTE: Without a concentration technique, the presence of both motile and non-motile spermmay not be detected. The method for detection of motile and non-motile sperm and thelaboratory findings must be clearly communicated on the patient report so that the clinician caninterpret the results in context to the method performed. The decision on the method used andextent of testing to be performed should be made in consultation with the medical staff served.

The American Urological Association (AUA) Vasectomy Guideline recommends a carefulevaluation of an uncentrifuged specimen, and does not recommend centrifugation of thespecimen for further assessment. The AUA Guideline also recommends reporting both thepresence and absence of sperm and presence or absence of sperm motility on the patient report.If no sperm are seen in the uncentrifuged specimen, the guideline recommends reporting that thepresence of sperm is below the limit of detection.

Evidence of Compliance:✓ Patient report with concentration findings or appropriate comment indicating that

concentration was not performed

REFERENCES1) Evaluation of the Azoospermic Male. Fertil Steril. 2008; 90 (S74-7)

2) Diagnostic Evaluation of the Infertile Male: A Committee Opinion. Fertil Steril. 2012; 98:294-301

3) American Urological Association (AUA) Guideline. American Urological Association Education and Research, Inc. 2012; amended2015. https://www.auanet.org/guidelines/vasectomy-(2012-amended-2015)

4) Vasectomy Update 2010. Can Urol Assoc J. 2010 October; 4(5):306-309

NOTE: If the laboratory only performs post-vasectomy checks, the remaining semen analysis requirements arenot applicable.

REQUISITIONS, SPECIMEN RECEIPT AND RESULTS REPORTING

LSV.43776 Specimen Collection/Handling Phase I

There are written patient instructions for collection and prompt delivery of a semensample to the laboratory.

NOTE: This should be written in simple terms in a language readily understood by the patient.Elements should include the need to abstain from ejaculation for 2-7 days before collection of thespecimen, avoidance of lubricants and other contamination, completeness of collection, use ofthe supplied container, maintenance of sample temperature, and prompt delivery. Instructionsmust be readily available and distributed to patients and to off-site physician offices that referspecimens.

REFERENCES1) WHO laboratory manual for the examination and processing of human semen, most recent editions (ie, fourth edition 1999 and fifth

edition 2010). New York, NY: Cambridge University Press

LSV.43782 Specimen Collection/Handling Phase I

Semen specimens are accompanied by the following collection information, and recordsare retained on the following.

1. Method of collection2. Type of specimen container3. Days of abstinence4. Collection or transport problems (eg, incomplete specimen, exposure to

temperature extremes)5. Time of specimen receipt and analysis

https://www.auanet.org/guidelines/vasectomy-(2012-amended-2015)

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LSV.43788 Liquefaction Phase I

All semen specimens are given sufficient time for liquefaction before testing.

Evidence of Compliance:✓ Written policy defining criteria for liquefaction



LSV.43794 Specimen Handling - Pre-analytic Phase I

Semen specimens are mixed thoroughly before testing.



LSV.43800 Specimen Characteristics - Analytic Phase I

All characteristics of the semen specimens are noted and reported (eg, gelatinousclumps, viscosity, contaminants, erythrocytes, and abnormalities of liquefaction).

NOTE: Macroscopic and microscopic characteristics of the semen specimens must be noted andreported, in accordance with the WHO laboratory manual for the examination of human semen(ie, fourth or fifth edition).

Evidence of Compliance:✓ Written policy defining characteristics to be included in the report

REFERENCES1) Haugen TB, Grotmol T. pH of human semen. Int J. Androl. 1998;21:105-108

2) WHO laboratory manual for the examination and processing of human semen, most recent editions (ie, fourth edition 1999 and fifthedition 2010). New York, NY: Cambridge University Press

SPERM MOTILITY

LSV.43804 Motility Method Verification Phase I

A procedure exists to verify the sperm motility method used (eg, video tapes/digitalimages of specimens with known percent motility and/or specific motion quality) and it isexercised at least semi-annually.

Evidence of Compliance:✓ Records of method verification

REFERENCES1) Mortimer D. Practical laboratory andrology. New York, NY: Oxford University Press, 1994

2) Yeung CH, et al. A technique for standardization and quality control of subjective sperm motility assessments in semen analysis.Fertil Steril. 1997;67:1156-1158

LSV.43807 Motility Quantification Phase II

Manual measures of percent sperm motility are quantified in a standardized manner.

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NOTE: The laboratory must have a written method for determining and reporting sperm motilityin their procedure manual that describes how sperm are assessed and counted (percent motility)and is based on a reference method, such as the World Health Organization (WHO) Standards(ie, fourth or fifth edition).


edition 2010). New York, NY: Cambridge University Press2) Yeung CH, et al. A technique for standardization and quality control of subjective sperm motility assessments in semen analysis.

Fertil Steril. 1997;67:1156-1158

LSV.43809 Forward Progression Phase II

Forward progression of sperm is evaluated.

Evidence of Compliance:✓ Written procedure for evaluation of forward progression AND✓ Patient reports or worksheets with results of forward progression


edition 2010). New York, NY: Cambridge University Press2) Vulcano GJ, et al. A lineal equation for the classification of progressive and hyperactive spermatozoa. Math Biosci. 1998;149:77-93

LSV.43812 Motility/Progression Evaluation Phase II

Sperm motility percent and progression are routinely evaluated within one hour ofcollection.

Evidence of Compliance:✓ Written procedure with requirement for motility evaluation AND✓ Records indicating time of collection and evaluation AND✓ Patient reports noting exceptions, when appropriate



LSV.43818 Standard Temperature Range Phase II

The laboratory has established a standard temperature range for semen analysisassessment, and deviations from this temperature are noted on the report.

NOTE: Specimen motility is temperature-dependent. Temperature ranges must be defined.

Evidence of Compliance:✓ Written procedure with acceptable temperature range defined✓ Records showing monitoring of temperatures



LSV.43824 Motility Microscopic Examination Phase II

The laboratory has written instructions for evaluating a sufficient number of separate andrandomly chosen microscopic fields and sperm cells.



LSV.43833 Viability Testing Criteria Phase I

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The laboratory performs viability testing on specimens with low percent motility (eg, lessthan 30%), or includes a comment that the decreased motility may be the result of non-viable or non-motile sperm.

NOTE: Non-motile sperm may represent forms that were originally non-viable in the ejaculate,or previously motile forms that have subsequently lost motility. Thus, viability assessment isuseful in making the distinction, and is commonly performed with a dye-exclusion method suchas eosin-nigrosin.

Evidence of Compliance:✓ Written procedure for viability testing AND✓ Patient records or worksheet with results of viability testing OR patient report with cautionary

verbiage


edition 2010). New York, NY: Cambridge University Press2) Gunalp S, et al. A study of semen parameters with emphasis on sperm morphology in a fertile population: an attempt to develop

clinical thresholds. Hum Repro. 2001;16:110-114

STAINED SMEAR - SPERM DIFFERENTIAL

LSV.43842 Morphology Classification Phase I

The sperm morphology classification method used is indicated on the report.

NOTE: Different classification systems have different reference intervals for normality. Toimprove the consistency and usefulness of reporting, CAP recommends the use of the WHOStandards (ie, fourth or fifth edition), and the Kruger classification system, and discontinuing theuse of older classification systems.

REFERENCES1) Kruger, T.F., et al. Sperm morphology features as a prognostic factor in vitro fertilization. Fertility and Sterility 46:1118-1123, 1986


3) Gunalp S, et al. A study of semen parameters with emphasis on sperm morphology in a fertile population: an attempt to developclinical thresholds. Hum Repro. 2001;16:110-114

**REVISED** 09/17/2019LSV.43848 Morphologic Observation Evaluation - Sperm Phase II

The laboratory evaluates consistency of morphologic observation among personnelperforming microscopic morphologic classification of sperm and other cells at leastannually.

NOTE: The laboratory must ensure the identification of sperm and other cells is reportedconsistently amongst all personnel performing the microscopic analysis.


1. Circulation of a pre-graded set of stained semen smears with defined specificqualitative abnormalities of sperm

2. Multi-headed microscopy3. Use of current published references4. Digital images


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REFERENCES1) Souter VL, et al. Laboratory techniques for semen analysis; a Scottish survey. Health Bull (Edinb). 1997;55:140-149

2) Baker DJ, Witmyer J. Semen analysis training tool. Chicago, IL: American Society of Clinical Pathologists Press, 1998


4) Kruger T, Frenken D. Atlas of Human Sperm Morphology Evaluation; Taylor & Frances, 2004

5) Glassy E. CAP Color Atlas of Hematology, 1998

LSV.43854 Consultation Phase II

An individual with expertise in sperm morphology (the pathologist, laboratory director,supervisor, or other technologist) is available for consultation, when needed.

REFERENCES1) Revised guidelines for human embryology and andrology laboratories. Fertil Steril. 2008;90 (suppl 3):S45-S59

LSV.43856 Sperm Morphology Reference Phase I

There is a file of unusual slides or current atlas of sperm morphology, available fortraining and reference.


edition 2010). New York, NY: Cambridge University Press2) Kruger T, Frenken, D. Atlas of Human Sperm Morphology Evaluation, Taylor & Frances, 2004

LSV.43857 Stain Usage Phase I

Stains are used to facilitate morphologic classification of cell types in semen (as opposedto performing differentials of unstained preparations).

Evidence of Compliance:✓ Written procedure for the use of stains for cell classification

REFERENCES1) Coetzee K, et al. Predictive value of normal sperm morphology: a structured literature review. Hum Reprod Update. 1998;4:73-82

LSV.43859 White Cell Confirmation Techniques Phase I

There is an additional procedure beyond unstained brightfield microscopy to ensure theaccurate distinction of leukocytes from other round cells (eg, Wright's, Papanicolaou,leukocyte alkaline phosphatase, or myeloperoxidase stains).

NOTE: This requirement only applies to laboratories that differentiate leukocytes from otherround cells on the patient report.

Evidence of Compliance:✓ Patient records or worksheets indicating use of additional procedure


edition 2010). New York, NY: Cambridge University Press2) Fishel TJ, et al. Increased polymorphonuclear granulocytes in seminal plasma in relation to sperm morphology. Hum Reprod.

1997;12:2418-24213) Zimmermann BS, et al. Relationship of bacteriological characteristics to semen indices and its influence on fertilization and

pregnancy rates after IVF. Acta Obstet Gynecol Scand. 1997;76:964-9684) Trum JW, et al. Value of detecting leukocytospermia in the diagnosis of genital tract infection in subfertile men. Fertil Steril.

1998;70:315-319

LSV.43862 Stain QC Phase II

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Quality control of all stains is performed and recorded to check for contamination andintended reactivity each day of use.

Evidence of Compliance:✓ Written procedures for stain QC AND✓ Records of stain QC


amendments of 1988; final rule. Fed Register. 2003(Jan 24):7166 [42CFR493.1256(e)(2)]2) Mortimer D. Practical laboratory andrology. New York, NY: Oxford University Press, 1994

LSV.43866 Stain Quality Phase II

The stains used (Wright's, Papanicolaou, eosin-nigrosin, peroxidase etc.) and slidepreparations are of sufficient quality to demonstrate the cellular characteristics for whichthey are designed.

NOTE: The stains used for semen analysis must be defined in the laboratory's proceduremanual.

Evidence of Compliance:✓ Examples of each type of stained slide available for microscopic review by inspector, as

applicable

AUTOMATED SEMEN ANALYSIS INSTRUMENTS

Various systems are in use and some requirements may not apply to every system. The requirements areintended to check factors common to automated systems. Inspectors should use individual judgment in applyingthe requirements to the particular type of system being used.

CALIBRATION AND QUALITY CONTROL

Several different methods may be used for calibration and quality control in the automated analysis of semencharacteristics. "Calibration" techniques include use of:

1. Multiple analyzed sperm specimens2. Stabilized preparations of sperm cells (eg, fixed or preserved)3. Sperm surrogates (eg, latex particles)4. Digital images/videotaped sperm specimens

NOTE: If stabilized control materials are used, they must represent different analytic levels (eg, normal andhigh). Similarly, retained patient specimens must be of differing counts and/or motility, as applicable.

LSV.43962 Calibration Materials Phase II

Calibration is verified with materials appropriate to the reportable range of the instrument,and verification is recorded.

NOTE: The quality control procedure for the automated instrument must include calibration andevaluation using defined limits of agreement with manually counted semen smears or storeddigital images, as appropriate for the particular system. Laboratories must verify at least every sixmonths that instruments are functioning correctly and are in control.


amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1255]2) Revised guidelines for human embryology and andrology laboratories. Fertil Steril. 2008;90 (suppl 3):S45-S59

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LSV.44010 Daily QC Phase II

The laboratory performs and records quality control for the automated instrument duringeach day of use, following the manufacturer instructions or using at least two levels ofcontrol at different concentrations.

REFERENCES1) Revised guidelines for human embryology and andrology laboratories. Fertil Steril. 2008;90 (suppl 3):S45-S59

2) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvementamendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1256(d)]



Evidence of Compliance:✓ Written policy defining criteria AND✓ Records of recalibration, if calibration or calibration verification has failed


amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1255(a)(3)]2) WHO laboratory manual for the examination and processing of human semen, most recent editions (ie, fourth edition 1999 and fifth


LSV.44106 Calibration Material Validation Phase II

The material used for calibration is validated using primary reference procedures (eg,manual counts).

Evidence of Compliance:✓ Written procedure identifying calibration materials and validation of materials used AND✓ Records showing accuracy of calibration materials used to include manufacturer's

certification/validation of commercial products OR in-house validation data

REFERENCES1) World Health Organization. Laboratory manual for the examination of human semen and sperm-cervical mucus interaction, 4th

edition. New York, NY: Cambridge University Press, 19992) Krause W. [Value of computer-assisted sperm analysis (CASA). reproducibility--online documentation--prognostic value]. [Article in

German]. Fortschr Med. 1996;114:470-4733) Tsuji T, et al. Automated sperm concentration analysis with a new flow cytometry-based device, S_FCM. Am J Clin Pathol.

2002;117:401-408

LSV.44154 System Control Phase II

If a manual method is used as the system control for automated sperm counts, itsaccuracy is verified and recorded at intervals appropriate for laboratory volume.

REFERENCES1) Mortimer D. Practical laboratory andrology. New York, NY: Oxford University Press. 1994

2) Lenzi A. Computer-aided semen analysis (CASA) 10 years later: a test-bed for the European scientific andrological community. Int JAndrol. 1997;20:1-2

3) Mahmoud AM, et al. Performance of the sperm quality analyser in predicting the outcome of assisted reproduction. Int J Androl.1998;21:41-46

4) Tsuji T, et al. Automated sperm concentration analysis with a new flow cytometry-based device, S_FCM. Am J Clin Pathol.2002;117:401-408

LSV.44202 Acceptable Limits - Controls Phase II

Acceptable limits are established for the value of each quality control sample.

Evidence of Compliance:✓ Records of defined acceptable limits for control range of each lot

LSV.44250 Sperm Concentration Range Phase II

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For automated sperm counts and motility, there is a written procedure to confirm that theconcentration of the specimen is within the range appropriate for automated analysis.

REFERENCES1) Vantman DD, et al. Computer assisted semen analysis: evaluation of method and assessment of the influence of sperm

concentration on linear velocity determination. Fertil Steril. 1988;49:510-5152) Yeung CH, et al. A technique for standardization and quality control of subjective sperm motility assessments in semen analysis.

Fertil Steril. 1997;67:1156-11583) Sidhu RS, et al. accuracy of computer-assisted semen analysis in prefreeze and post-thaw specimens with high and low sperm

counts and motility. Urology. 1998;51:306-3124) Tsuji T, et al. Automated sperm concentration analysis with a new flow cytometry-based device, S_FCM. Am J Clin Pathol.

2002;117:401-408


Upper and lower limits of all reportable parameters on instruments are defined, andresults that fall outside these limits are reported properly.

NOTE: Results that fall outside of these limits may be verified by repeating the test, using analternative method or diluting/concentrating the specimen, as appropriate.

Evidence of Compliance:✓ Written policy defining the upper and lower reporting limits and verification of results AND✓ Patient test verification records

REFERENCES1) Mortimer D. Practical laboratory andrology. New York, NY: Oxford University Press. 1994

**REVISED** 09/17/2019LSV.44394 Calibration Verification Criteria Phase II

There are written criteria for method calibration verification.


1. At complete changes of reagents, unless the laboratory can demonstrate thatchanging reagent lots does not affect either the range used to report patient testresults or the control values



For automated semen analysis instruments, requirements for calibration verification may beconsidered met if the laboratory follows the manufacturer's instructions for instrument operationand tests two levels of control materials each day of testing. The control results must meet thelaboratory's criteria for acceptability.

Evidence of Compliance:✓ Written policy defining the method, frequency, and limits of acceptability of calibration

verification for each instrument/test system AND✓ Records of calibration verification documented at defined frequency


amendments of 1988; final rule. Fed Register. 2003(Jan 24):7165 [42 CFR 493.1255]

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MICROBIOLOGY SECTION

Microbiology activities for this Checklist are LIMITED to specimen collection, direct microscopy for organisms(eg, Gram stain for bacteria, potassium hydroxide for fungi, pinworm preparation), direct antigen testing,and initial culture plating or similar activity before transport to a microbiology laboratory. If the limited servicelaboratory performs any cultures, including blood cultures and culture reporting of “no growth," antimicrobialsusceptibility testing, or molecular microbiology, this Checklist is NOT sufficient, and the Microbiology Checklistmust be used.

SPECIMEN COLLECTION AND HANDLING - MICROBIOLOGY

Culture specimens are often collected by nurses or others outside the laboratory. An important aspect of qualitycontrol is the provision of adequate instructions to ensure proper collection and handling of specimens beforethey are received by the laboratory.


● Sampling of specimen collection and handling policies and procedures● Sampling of requisitions for completeness● Records of blood culture contamination rate monitoring

● Sampling of microbiology specimens (transport media, timely delivery, labeling)

● What is your course of action when you receive unacceptable microbiologyspecimens?

LSV.44530 Unacceptable Sputum Specimens Phase I

Specimens deemed unacceptable by Gram stain review are not cultured for routinebacteria (or cultured only by special request) and the health care provider or submittinglaboratory is notified so another specimen can be collected without delay, if clinicallyindicated.

NOTE: It is suggested that the laboratory notify an appropriate caregiver about an inadequatespecimen even when specimens are submitted from an outpatient setting, or submitted toa referral laboratory. Notification can be by phone or computer report. The laboratory mayimplement written agreements with particular providers or submitting laboratories definingpolicies for handling sputum samples.

Evidence of Compliance:✓ Records of specimen rejection such as rejection log or patient report

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REFERENCES1) Bartlett RC. Medical microbiology: quality cost and clinical relevance. New York, NY: Wiley, 1974:24-31

2) Carroll KC. Laboratory Diagnosis of Lower Respiratory Tract Infection: Controversy and Conundrums. J Clin Microbiol.2002;3115-3120

**REVISED** 06/04/2020LSV.44610 Blood Culture Collection Phase II

Sterile techniques for drawing and handling of blood cultures are defined, made availableto individuals responsible for specimen collection, and practiced.

Evidence of Compliance:✓ Written procedure for blood culture collection

REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Principles and Procedures for Blood Cultures; Approved Guideline. CLSI

Document M47-A (ISBN 1-56238-641-7). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA19087-1898 USA, 2007.

2) Baron EJ, et al. Blood Cultures IV, Cumitech 1C, 2005, ASM Press; Washington, DC

3) Jorgensen JH (ed), et al. Manual of Clinical Microbiology. 11th ed. Washington, DC: ASM Press; 2015.

4) Leber, AL (ed). Clinical Microbiology Procedures Handbook. 4th ed. Washington DC: ASM Press; 2016.

**NEW** 06/04/2020LSV.44620 Blood Culture Contamination Phase II

The laboratory monitors blood culture contamination rates and has established anacceptable threshold.

NOTE: The laboratory must determine and regularly review the number of contaminatedcultures. Tracking the contamination rate and providing feedback to units and persons drawingcultures is one method that has been shown to reduce contamination rates. Other measuresfor consideration in monitoring blood culture contamination include the types of skin disinfectionused and line draws.

The threshold may be established in collaboration with other relevant institutional groups (eg,infection prevention). The laboratory must perform and record corrective action if the threshold isexceeded.

Evidence of Compliance:✓ Written procedure for monitoring blood culture contamination rates and threshold

determination AND✓ Records of contamination rates and corrective action if threshold is exceeded AND✓ Records of feedback to responsible parties

REFERENCES1) Bekeris LG, Tworek JA, Walsh MD, Valenstein PN. Trends in blood culture contamination: a College of American Pathologists Q-

TRACKS study of 365 institutions. Arch Pathol Lab Med. 2005;129:1222-5.2) Clinical and Laboratory Standards Institute (CLSI). Principles and Procedures for Blood Cultures; Approved Guideline. CLSI

Document M47-A. Clinical and Laboratory Standards Institute. Wayne, PA, 2007.

**REVISED** 09/17/2019LSV.44690 Blood Culture Volume Phase I

The laboratory has a written policy and procedure for monitoring blood cultures fromadults for adequate volume and feeding back the results to blood collectors.

NOTE: Larger volumes of blood increase the yield of true positive cultures. The volume collectedmust be in accordance with manufacturer instructions (in most systems it is 20 mL).Thelaboratory should periodically monitor collected blood volumes and provide feedback to clinicalstaff. Automated blood culture systems approved or cleared by the FDA may use smallervolumes per culture set and are acceptable.

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Evidence of Compliance:✓ Records of monitoring of volume at a defined frequency AND✓ Records of feedback to the clinical staff

REFERENCES1) Novis DA, et al. Solitary blood cultures. A College of American Pathologists Q-Probes study of 132778 blood culture sets in 333 small

hospitals. Arch Pathol Lab Med. 2001;125:1290-12942) Clinical and Laboratory Standards Institute (CLSI). Principles and Procedures for Blood Cultures; Approved Guideline. CLSI

Document M47-A (ISBN 1-56238-641-7). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA19087-1898 USA, 2007.

3) Baron EJ, et al. Blood Cultures IV, Cumitech 1C, 2005, ASM Press; Washington, DC

LSV.44740 Requisitions Phase I

Requests for analysis include source of specimen, test or tests requested and, whenappropriate, type of infection and/or organism expected.


amendments of 1988; final rule. Fed Register. 2003(Jan 24):7162 [42CFR493.1241(c)]

LSV.44770 Specimen Collection/Handling Phase II

There are written instructions for microbiology specimen collection and handling thatinclude all of the following.

1. Method for proper collection of culture specimens from different sources2. Proper labeling of culture specimens3. Use of appropriate transport media when necessary4. Policies for safe handling of specimens (tightly sealed containers, no external

spillage)5. Need for prompt delivery of specimens to ensure minimum delay and

processing (eg, CSF, wound cultures, anaerobes)6. Method for preservation of specimens if processing is delayed (eg,

refrigeration of urines)

NOTE: Manufacturer's recommendations must be followed when there is a delay in delivery orprocessing of specimens for automated instruments (eg, blood culture instruments).

REFERENCES1) Jorgensen JH (ed), et al. Manual of Clinical Microbiology. 11th ed. Washington, DC: ASM Press; 2015.

LSV.44775 Group B Streptococcus Screen Phase II

Group B streptococcus screens from pregnant women are collected and cultured inaccordance with the current guidelines.

NOTE: Universal prenatal screening for vaginal and rectal Group B streptococcal (GBS)colonization of all pregnant women at 35-37 weeks gestation is recommended. The optimumspecimen for this test is a vaginal/rectal swab and results may be compromised if only avaginal swab is submitted. Detection of GBS in urine cultures in this population should also beaddressed. Procedures for collecting and processing clinical specimens for GBS culture andperforming susceptibility testing to clindamycin and erythromycin for highly penicillin allergicwomen are also included in the guidelines.

REFERENCES1) Center for Disease Control and Prevention, 2010. Prevention of perinatal Group B streptococcal disease MMWR 59(RR-10);1-32

LSV.44780 Stool Specimen Number/Timing Phase I

There are written policies for the number and/or timing of collection of stool specimenssubmitted for routine bacterial testing.

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NOTE: The laboratory should consider developing policies with its clinicians for the number and/or timing of collection of stool specimens submitted for routine bacterial testing. Suggestionsmade by the authors of a 1996 CAP Q-Probes study (Valenstein et al) include:

1. Accept no more than two specimens/patient without prior consultation with anindividual who can explain the limited yield provided by additional specimens

2. Do not accept specimens from inpatients after the third hospital day, without priorconsultation

3. Test stool for Clostridiodes difficile toxin for all patients with clinically significantdiarrhea and a history of antibiotic exposure. Consider C. difficile testing as analternative to routine microbiologic studies for inpatients who have test requests forroutine enteric pathogens

4. Positive test results for Clostridiodes difficile do not correlate well with disease inyoung children. Follow manufacturer's guidelines for guidance on the testing ofpediatric patients.

These recommendations are for diagnostic testing. Different policies may apply to tests orderedfor follow-up.

REFERENCES1) Yannelli B, et al. Yield of stool cultures, ova and parasite tests, and Clostridium difficile determinations in nosocomial diarrhea. Am J

Infect Control. 1988;16:246-2492) Siegel DL, et al. Inappropriate testing for diarrheal diseases in the hospital. JAMA. 1990;263:979-982

3) Asnis DS, et al. Cost-effective approach to evaluation of diarrheal illness in hospitals. J Clin Microbiol. 1993;31:1675

4) Fan K, et al. Application of rejection criteria for stool cultures for bacterial enteric pathogens. J Clin Microbiol. 1993;31:2233-2235

5) Valenstein P, et al. The use and abuse of routine stool microbiology. A College of American Pathologists Q-probes study of 601institutions. Arch Pathol Lab Med. 1996;120:206-211

6) Wilson ML. Clinically relevant, cost-effective clinical microbiology. Strategies to decrease unnecessary testing. Am J Clin Pathol.1997;107:154-165

7) Blackman E, et al. Cryptosporidiosis in HIV-infected patients: diagnostic sensitivity of stool examination, based on number ofspecimens submitted. Am J Gastroenterol. 1997;92:451-453

8) Wood M. When stool cultures from adult inpatients are not appropriate. Lancet. 2001;357:901-902

9) Bauer, TM, et al. Derivation and validation of guidelines for stool cultures for enteropathogenic bacteria other than Clostridium difficilein hospitalized patients. JAMA. 2001;285:313-319

**REVISED** 09/17/2019LSV.44785 Stool Number/Timing Phase I

There are written policies for the number and/or timing of collection of stool specimenssubmitted for routine parasitology testing.

NOTE: The laboratories should consider developing policies with its clinicians for the numberand/or timing of collection of stool specimens submitted for routine parasitology testing.

Suggestions made by the authors of a 1996 CAP Q-Probes study (Valenstein et al) include:

1. Accept no more than two or three specimens/patients without prior consultation withan individual who can explain the limited yield provided by additional specimens

2. Do not accept specimens from inpatients after the fourth hospital day, without priorconsultation

These recommendations are for diagnostic testing. Different policies may apply to tests orderedfor follow-up.

REFERENCES1) Yannelli B, et al. Yield of stool cultures, ova and parasite tests, and Clostridium difficile determinations in nosocomial diarrhea. Am J

Infect Control. 1988;16:246-2492) Morris AJ, et al. Application of rejection criteria for stool ovum and parasite examinations. J Clin Microbiol. 1992;30:3213-3216

3) Valenstein P, et al. The use and abuse of routine stool microbiology. A College of American Pathologists Q-probes study of 601institutions. Arch Pathol Lab Med. 1996;120:206-211

4) Cartwright CP. Utility of multiple-stool-specimen ova and parasite examinations in high-prevalence setting. J Clin Microbiol.1999;37:2408-2411

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LSV.44790 Centrifugation of Body Fluids Phase I

If only plated media are used for sterile body fluids, fluid is centrifuged and the sedimentused to inoculate media unless the entire specimen is plated.

NOTE: If insufficient specimen is received for centrifugation/concentration when specified in thewritten procedure, the report should note that the culture results may be compromised by thelimited volume of specimen received. Equivalent methods are acceptable, if validated by thelaboratory.

REFERENCES1) Versalovic, James. Manual of Clinical Microbiology - 10th Edition. Washington, DC: ASM Press. 2011

LSV.44795 CSF Processing Phase II

CSF samples for culture are processed immediately on receipt.

NOTE: Bacterial meningitis is a critical condition that requires immediate attention. Samples mustbe processed upon receipt when meningitis is suspected. The laboratory may choose to handlesurveillance cultures, eg, involving neurosurgical implants, differently.

Evidence of Compliance:✓ Policy and procedure for CSF processing AND✓ Culture log or patient records

LSV.44798 Anaerobic Cultures Phase I

The laboratory has written policies defining when to culture for anaerobes.

NOTE: The policy must define criteria to determine if the submitted material is of sufficient qualityto provide an interpretable result.

If the laboratory does not perform anaerobic cultures on-site, the laboratory must refer specimensto a referral laboratory for anaerobic culture when indicated.

LSV.44799 Anaerobic Cultures Phase II

There are written procedures describing how to culture anaerobic organisms whenindicated.

NOTE: For example, the minimum standards for the evaluation of deep wound culturesrequire adequate procedures for the collection, recovery and identification of clinically relevantpathogens, which includes aerobic, facultatively anaerobic, and strictly anaerobic organisms.Anaerobic organisms may be significant isolates from other specimen types as well. Suggestedmedia for anaerobes include an anaerobic blood agar plate, a medium that inhibits gram-positiveand facultative gram-negative bacilli such as KV blood agar, a differential or selective mediumsuch as BBE (Bacteroides bile-esculin), and a gram-positive selective medium (colistin-nalidixicacid blood agar or phenylethyl alcohol blood agar). Provisions for adequate anaerobic incubation,with monitoring of the anaerobic environment, must be available. If specimens are referredto another laboratory, they must be transported in an expeditious fashion under appropriateconditions.

REFERENCES1) Clinical and Laboratory Standards Institute. Principles and Procedures for Detection of Anaerobes in Clinical Specimens; Approved

Guideline. CLSI document M56-A. Clinical and Laboratory Standards Institute, Wayne, PA; 2014

LSV.44805 Specimen Collection/Transport Phase I

Specimens for mycobacterial testing are collected appropriately and transported to thelaboratory without delay.

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NOTE: The laboratory should recommend collecting three sputum specimens for acid-fastsmears and culture in patients with clinical and chest x-ray findings compatible with tuberculosis.These three samples should be collected at 8-24 hour intervals and should include at least onefirst morning specimen. Specimens must be delivered to the laboratory promptly; specimensthat cannot be processed within one hour of the time of collection should be refrigerated duringtransport to and storage in the laboratory prior to processing. This will decrease overgrowth withcontaminating organisms likely to be present.

Laboratories are encouraged to process acid-fast specimens in their laboratory or obtain resultsfrom referral laboratories as soon as possible so that smear results can be available within 24hours of collection (see MIC.31200 below).

Evidence of Compliance:✓ Written policy describing specimen collection and handling requirements

REFERENCES1) Toman K. How many bacilli are present in a sputum specimen found positive by smear microscopy [Chapter 4]. In: Frieden T, ed.

Toman's tuberculosis case detection, treatment, and monitoring: questions and answers. 2nd ed. Geneva, Switzerland: World HealthOrganization; 2004:11-3

2) Siddiqui AH, Perl TM, Conlon M, Donegan N, Roghmann MC. Preventing nosocomial transmission of pulmonary tuberculosis: whenmay isolation be discontinued for patients with suspected tuberculosis? Infect Control Hosp Epidemiol 2002;23:141-4

3) CDC. "Treatment of Tuberculosis: American Thoracic Society, CDC, and Infectious Diseases Society of America" MMWR 2003:52(No.RR-11)

4) Hopewell PC, Pai M, Maher D, et al. International Standards for Tuberculosis Care. Lancet 2006;6:710-25

5) Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings. MMWR, 2005; 54(RR17);1-141.

LSV.44810 Selective Media Phase II

Suitable selective media are used for the growth and isolation of dermatophytes and/orsystemic fungi.

Evidence of Compliance:✓ Written policy for mycology culture defining the media used for growth and isolation

LSV.44815 Viral Culture Specimens Phase I

Specimens for viral culture are collected appropriately and transported to the laboratorywithout delay.

NOTE: The laboratory must provide procedures for the appropriate collection, transport andstorage of all specimen types tested in the laboratory. Specimens should be delivered to thelaboratory promptly, ideally within 2-4 hrs of sample collection and preferably within 1 dayof collection. This may not be possible for laboratories that refer samples to offsite referrallaboratories for viral testing. In these instances samples must be stored and shipped underconditions that would preserve the integrity of the sample. Unless otherwise indicated, specimensshould be refrigerated or frozen depending on the duration of storage prior to testing.

REFERENCES1) Clinical and Laboratory Standards Institute. Viral Culture; Approved Guideline. CLSI document M41-A. Clinical and Laboratory

Standards Institute, Wayne, PA, 2006.2) Ginocchio, CC. Quality Assurance in Clinical Virology. In: Spector S, Hodinka RL, Young SA, editors. Clinical Virology Manual.

Fourth Edition. Washington: ASM Press; 2009.p. 3-17

LSV.44820 Specimens for Molecular Amplification Phase II

The laboratory has written procedures for the handling of specimens that will be testedusing molecular amplification methods.

NOTE: Special precautions must be taken to avoid sample cross-contamination that may notaffect culture-based methods but may lead to false positive results when tested using molecularamplification methods.

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REFERENCES1) Clinical and Laboratory Standards Institute (CLSI). Collection, Transport, Preparations, and Storage of Specimens for Molecular

Methods; Approved Guideline. CLSI document MM13-A (ISBN 1-56238-591-7). Clinical and Laboratory Standards Institute, 940West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898 USA, 2005.

REPORTING OF RESULTS


● Sampling of patient preliminary reports● Sampling of bacteriology test procedures● Sampling of patient worksheets/records

LSV.45180 Preliminary Reports Phase I

When indicated, preliminary reports are promptly generated.

Evidence of Compliance:✓ Written policies defining when preliminary results are issued

LSV.45290 Clostridioides (Formerly Clostridium) difficile Phase II

There are written policies for the testing of stool for the detection and reporting of C.difficile or its toxins.

REFERENCES1) Novak-Weekley SM, et al. Clostridium difficile testing in the Clinical Laboratory by Use of Multiple Testing Algorithms. Journal of

Clinical Microbiology 2010; 48:889-8932) Eastwood K, et al. Comparison of Nine Commercially Available Clostridium difficile Toxin Detection Assays, a Real-Time PCR Assay

for C. difficile tcdB and a Glutamate Dehydrogenase Detection Assay to Cytotoxin Testing and Cytotoxigenic Culture Methods.Journal of Clinical Microbiology 2009; 47:3211-3217

3) Peterson LR and Robicsek A. Does my Patient have Clostridium difficile Infection? Annals of Internal Medicine 2009; 151:176-178

INSTRUMENTS AND EQUIPMENT - MICROBIOLOGY


● Sampling of incubator monitoring records

**REVISED** 09/17/2019LSV.45297 CO2 Incubator Levels Phase I

CO2 incubators are checked daily for adequate CO2 levels, with recording of results.

NOTE: It is acceptable to monitor and record CO2 levels from digital readouts; however, thelaboratory must verify that the readout is accurate (by initial calibration, Fyrite, or other calibratedCO2 meter). The frequency of verification of the digital readout must be defined and should beperformed, at minimum, at the frequency recommended by the manufacturer.

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MEDIA


● Sampling of media QC policies and procedures● Sampling of media supplier records of QC● Sampling of records for QC performed by the laboratory

● Sampling of media (expiration date, condition, contamination)

● What is your QC procedure when receiving a new lot of media?

● Follow a shipment of new media from receipt, examination and QC (if applicable).Determine if practice follows laboratory policy.

LSV.45360 Inspection of Media Shipments Phase I

The laboratory has records showing that each shipment of purchased media is examinedfor breakage, contamination, appearance, and evidence of freezing or overheating.

REFERENCES1) Clinical and Laboratory Standards Institute. Quality Control for Commercially Prepared Microbiological Culture Media; Approved

Standard; 3rd ed. CLSI document M22-A3. Clinical and Laboratory Standards Institute, Wayne, PA, 2004.

**REVISED** 09/17/2019LSV.45390 Media QC - Purchased Phase II

An appropriate sample from each lot and shipment of each purchased medium is checkedbefore or concurrent with initial use for each of the following:

1. Sterility2. Ability to support the growth of organisms intended to be isolated on the

media by means of stock cultures or by parallel testing with previous lots andshipments

3. Biochemical reactivity, where appropriate

NOTE: The laboratory must have records showing that all media are sterile, able to supportgrowth, and are appropriately reactive biochemically.

An individualized quality control plan (IQCP), including all required elements of IQCP, maybe implemented by the laboratory to allow for the acceptance of the quality control performedby the media supplier for media listed as "exempt" in the CLSI Standard M22-A3, QualityControl for Commercially Prepared Microbiological Culture Media. The media supplier's records

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must be retained and show that the QC performed meets the CLSI standard and checklistrequirements. Please refer to the IQCP section of the All Common Checklist for the requirementsfor implementation and ongoing monitoring of an IQCP. End user quality control must beperformed on the following, regardless of the exempt status:

● Campylobacter agar;● Chocolate agar;● Media for the selective isolation of pathogenic Neisseria;● Other media not listed on Table 2 of M22-A3 (eg, dermatophyte test medium);● Media used for the isolation of parasites, viruses, Mycoplasmas, Chlamydia;● Mueller-Hinton media used for antimicrobial susceptibility tests; or● Media commercially prepared and packaged as a unit or system consisting of two or

more different substrates, primarily used for microbial identification.

Laboratories receiving media from media suppliers must have records showing that the qualitycontrol activities performed by the media supplier meet the CLSI Standard M22-A3, or areotherwise equivalent. Problems with media deterioration or loss of reactivity in properly-storedmedia prior to the expiration date must be reported to the manufacturer, with records retained bythe laboratory as part of corrective action.

Laboratories using exempt media that have not implemented an IQCP or are using media that donot qualify for an IQCP must continue to test each lot and shipment of media and retain recordsof such testing.

Evidence of Compliance:✓ Written procedure for QC on new lot numbers or shipments of purchased medium AND✓ Individualized quality control plan for the media approved by the laboratory director, as

applicable AND✓ Records of media quality control

REFERENCES1) Clinical and Laboratory Standards Institute. Quality Control for Commercially Prepared Microbiological Culture Media; Approved

Standard; 3rd ed. CLSI document M22-A3. Clinical and Laboratory Standards Institute, Wayne, PA, 2004.2) Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Disk Susceptibility Tests; Approved Standard.

13th ed. CLSI document M02. Clinical and Laboratory Standards Institute, Wayne, PA; 2018.3) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvement

amendments of 1988, final rule. Fed Register. 2003(Jan 24): [42CFR493.1256(e)]

LSV.45490 Media Visual Examination Phase II

All media are in visibly satisfactory condition (with expiration date, plates smooth,adequately hydrated, uncontaminated, appropriate color and thickness, tubed media notdried or loose from sides).

DIRECT SPECIMEN EXAMINATION


● Sampling of QC policies and procedures● Sampling of QC records

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● Sampling of microbiology smear preparations (uniquely identified, proper smearthickness, free of precipitate, proper cell distribution, appropriate staining reactions,etc.)


● Review a sampling of QC data over the previous two-year period. Select severaloccurrences in which QC is out of range and follow documentation to determine if thesteps taken follow the laboratory policy for corrective action

**NEW** 06/04/2020LSV.45560 Smear Preparation and Stain Quality Phase I

The quality of smear preparation and staining is satisfactory for all microbiology stains(ie, proper smear thickness, free of precipitate, proper cell distribution, appropriatestaining reactions, etc.).

NOTE: This can be evaluated by reviewing QC slides and random clinical slides.

REFERENCES1) Hata DJ, Thomson RB. Gram Stain Benchtop Reference Guide: An Illustrated Guide to Microorganisms and Pathology Encountered

in Gram-Stained Smears. Northfield, IL: College of American Pathologists; 2017.

LSV.45570 Quality Control Organisms Phase II

Appropriate quality control organisms are used to check stains, reagents andsusceptibility test methods.

NOTE:1. Quality control organisms may be ATCC strains or well characterized laboratory

strains unless specified by the manufacturer2. Quality control organisms are maintained in a manner to preserve their bioreactivity,

phenotypic characteristics and integrity

REFERENCES1) Jones RN, et al. Method preferences and test accuracy of antimicrobial susceptibility testing. Updates from the College of American

Pathologists microbiology surveys program (2000). Arch Pathol Lab Med. 2001;125:1285-1289

LSV.45676 Direct Antigen Test QC Phase II

For nonwaived direct antigen tests on patient specimens, positive and negative controlsare tested and recorded at least daily, or more frequently if specified in the manufacturer'sinstructions, laboratory procedure, or CAP Checklist.

NOTE: This requirement pertains to nonwaived tests with a protein, enzyme, or toxin whichacts as an antigen. Examples include, but are not limited to: Group A Streptococcus antigen, C.difficile toxin, fecal lactoferrin and immunochemical occult blood tests. For panels or batteries,controls must be employed for each antigen sought in patient specimens.

If an internal quality control process (eg, electronic/procedural/built-in) is used instead of anexternal control material to meet daily quality control requirements, the laboratory must have an

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individualized quality control plan (IQCP) approved by the laboratory director. Please refer to theIQCP section of the All Common Checklist for the eligibility of tests for IQCP and requirementsfor implementation and ongoing monitoring of an IQCP.

For each test system that requires an antigen extraction phase, as defined by the manufacturer,the system must be checked with an appropriate positive control that will detect problems inthe extraction process. If an IQCP is implemented for the test, the laboratory's quality controlplan must define how the extraction phase will be monitored, as applicable, based on the riskassessment performed by the laboratory and the manufacturer's instructions.

Evidence of Compliance:✓ Written QC procedures AND✓ Records of QC results including external and electronic/procedural/built-in control systems

AND✓ Manufacturer's product insert or manual


amendments of 1988, final rule. Fed Register. 2003(Jan 24): [42CFR493.1261(a)]

LSV.45712 CSF Back-Up Cultures Phase II

If bacterial antigen-detection methods are used, backup cultures are performed on bothpositive and negative CSF specimens.

NOTE: Total dependence on a bacterial antigen test for the diagnosis of bacterial meningitisdoes NOT meet accreditation requirements. Meningitis may be caused by bacteria not detectedby the antigen tests. Thus, culture is essential for proper evaluation of bacterial meningitis,and must be performed on the patient specimen - if not performed onsite by the laboratory, theinspector must seek evidence that a culture has been performed in a referral laboratory.

Evidence of Compliance:✓ Written policy stating that CSF cultures are performed in conjunction with bacterial antigen

tests OR policy describing testing at another location AND✓ Records of back-up CSF cultures performed on-site OR records that the cultures are

performed at another location OR records that the order for CSF bacterial antigen wasblocked by the computer due to no order for a culture

REFERENCES1) Forward KR. Prospective evaluation of bacterial antigen detection in cerebral spinal fluid in the diagnosis of bacterial meningitis in a

predominantly adult hospital. Diagn Micro Infect Dis. 1988;11:61-632) Maxson S, et al. Clinical usefulness of cerebrospinal fluid bacterial antigen studies. J Pediat. 1994; 125:235-238

3) Finlay FO, et al. Latex agglutination testing in bacterial meningitis. Arch Dis Child. 1995;73:160-161

4) Rathore MH, et al. Latex particle agglutination tests on the cerebrospinal fluid. A reappraisal. J Florida Med Assoc. 1995;82:21-23

5) Kiska DL, et al. Quality assurance study of bacterial antigen testing of cerebrospinal fluid. J Clin Micro. 1995;33:1141-1144

6) Perkins MD, et al. Rapid bacterial antigen detection is not clinically useful. J Clin Micro. 1995;33:1486-1491

LSV.45722 Group A Streptococcus Direct Antigen Detection Phase I

If group A Streptococcus direct antigen testing is performed on pediatric patients,confirmatory testing is performed on negative samples.

NOTE 1: Policies must be established for the use of cultures or other confirmatory testson pediatric specimens that test negative when using antigen detection methods or if themanufacturer's guidelines include recommendations for culture follow-up. These policies shouldtake into account the sensitivity of the assay in use, the age and clinical presentation of thepatient, and other factors.

NOTE 2: Direct antigen tests should be performed and reported in a timely fashion, since theirprincipal advantage (compared to culture) is rapid turn-around-time.

REFERENCES

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1) Shulman S, Bisno A, Clegg H, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A StreptococcalPharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10). doi: 10.1093/cid/cis629.

LSV.45732 Cryptococcal Antigen Phase II

If cryptococcal antigen-detection methods are used on CSF, back-up cultures areperformed on positive CSF specimens submitted for diagnosis.

NOTE: It is important to recover the causative organism for precise identification (C. neoformansvs. C. gattii) and potential susceptibility testing. Back-up cultures of follow-up specimens used fortrending the antigen titer are not required. If culture is not performed onsite by the laboratory, thelaboratory must show evidence that it has been performed in a referral laboratory.

Evidence of Compliance:✓ Written policy stating that CSF cultures are performed in conjunction with initial positive

cryptococcal antigen tests OR policy describing testing at another location AND✓ Records of back-up CSF cultures performed on-site OR records indicating that cultures are

performed at another location

MOLECULAR-BASED MICROBIOLOGY TESTING-WAIVED TESTS

The requirements in this section apply to molecular-based microbiology tests classified as waived performedin a limited service laboratory setting. Microbiology testing performed by nonwaived molecular-based methodsmust be inspected with the Microbiology Checklist.


● Sampling of QC statistics● Sampling of molecular microbiology specimen handling and processing policies and

procedures● Sampling test reports (test methodology, clinical interpretation)

● What is your course of action when monitored statistics increase above the expectedpositive rate?

**NEW** 09/17/2019LSV.45740 Quality Monitoring Statistics Phase I

There are written procedures to monitor for the presence of false positive results (eg, dueto nucleic acid contamination) for all molecular microbiology tests.

NOTE: Examples of this may include review of summary statistics (eg, monitoring percentage ofpositive results relative to current local and regional rates and increased positive Strep resultsabove historical rate within a run or over multiple runs), performance of wipe (environmental)testing, review and investigation of physician inquiries, and use of process controls to minimizerisk of contamination.

Evidence of Compliance:✓ Written procedure for monitoring for presence of false-positive results AND✓ Records of data review, wipe testing, statistical data evaluation and corrective action if

indicated

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REFERENCES1) Borst A, Box AT, Fluit AC. False-positive results and contamination in nucleic acid amplification assays: suggestions for a prevent

and destroy strategy. Eur J Clin Microbiol Infect Dis. 2004; 23(4):289-99.2) Cone RW, Hobson AC, Huang ML, Fairfax MR. Polymerase chain reaction decontamination: the wipe test. Lancet.1990; 336:686–

687.3) McCormack JM, Sherman ML, Maurer DH. Quality control for DNA contamination in laboratories using PCR- based class II HLA

typing methods. Hum Immunol. 1997;54:82–88.4) Clinical and Laboratory Standards Institute (CLSI). Establishing Molecular Testing in Clinical Laboratory Environments; 1st ed. CLSI

document MM19-A. Clinical and Laboratory Standards Institute, Wayne, Pennsylvania, 2011.

**NEW** 09/17/2019LSV.45745 Final Report Phase I

The final report includes a summary of the test method and information regarding clinicalinterpretation if appropriate.

NOTE: For tests that may be performed by either direct antigen or molecular-based methods(PCR), including the test method in the report is important for interpretation of the results. Thereport must include a brief description of the method if the methodology is not explicit in the testname.

STAINS


● Sampling of staining policies and procedures● Sampling of stain QC records/logs● Sampling of employee records of morphologic observation correlation

● Sampling of microbiology smear preparations (uniquely identified, proper smearthickness, free of precipitate, proper cell distribution, appropriate staining reactions,etc.)

● How do you ensure consistency among personnel performing microscopicmorphology?

LSV.45805 Direct Gram Stain Procedures Phase I

There are written policies for use of Gram stain results to provide a preliminaryidentification of organisms, evaluate specimen quality when appropriate, and to guidework-up of cultures.

NOTE: The laboratory should have policies for the interpretation of the Gram stain, includingthe quantification, stain reaction, and morphotypes of organisms and cells (eg, neutrophils orsquamous epithelial cells). The policy should address correlation of direct Gram stain results withfinal culture results.

This does not mean that interpretation of the Gram stain morphology suggesting aspecific organism identification (eg, gram positive diplococci morphologically suggestive ofpneumococcus) is required.

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Evidence of Compliance:✓ Written procedure for Gram stain (laboratories may use the correlation of Gram stain results

with the final culture results as a component of the QC program)

LSV.45810 Gram Stain QC Phase II

Quality control of Gram stain reagents is performed for intended reactivity and recordedfor each new batch or lot, and shipment of stains and at least weekly against known gram-positive and gram-negative quality control organisms.

NOTE: Personnel who perform Gram stains infrequently must run a gram-positive and gram-negative control each day of testing.

Evidence of Compliance:✓ Written procedure for Gram stain QC

REFERENCES1) August, Hindler, Huber, Sewell. Quality control and quality assurance practices. In: Clinical microbiology, Cumitech 3A. Washington,

DC: American Society for Microbiology, 19902) Department of Health and Human services, Centers for Medicare and Medicaid Services. Clinical laboratory improvement

amendments of 1988, final rule. Fed Register. 2003(Jan 24):3708 [42CFR493.1261(a)(2)]

LSV.45812 Bacterial Vaginosis Phase I

When Gram stains are performed to make the laboratory diagnosis of bacterial vaginosis,the smear is scored and interpreted according to published criteria.

NOTE: Culture should not be used for the diagnosis of bacterial vaginosis. Bacterial vaginosis(BV) is a syndrome involving a shift in the concentrations of aerobic and anaerobic flora of thegenitourinary tract flora from a predominant presence of Lactobacillus sp. to that of a mixtureof anaerobes, Gardnerella vaginalis and other gram-negative bacteria. Culturing for a particularorganism, such as Gardnerella vaginalis, or any single organism or combination of organisms isnot specific for the diagnosis of BV. Use of a scored Gram stain that demonstrates whether therehas been a shift in the vaginal flora from predominantly gram-positive Lactobacillus to a gram-negative flora has been shown to correlate well with the Amsel criteria for the diagnosis of BV.The primary reason for performing a Gram stain on vaginal secretions is to diagnose bacterialvaginosis.

REFERENCES1) Nugent RP, Krohn MA, Hillier SL. 1991. JCM 29;297-301

2) Forsum U, Hallen A, Larsson PG. Bacterial Vaginosis - a laboratory and clinical diagnostic enigma. Review article III. APMIS 113:153-61. 2005

LSV.45814 Tzanck Test Phase I

Slides for the Tzanck test are of sufficient quality for diagnosis.

NOTE: Slides must be of adequate technical quality to be diagnostically useful. The laboratoryshould have access to a photographic atlas appropriate to the diagnostic purpose and method(eg, Papanicolaou or Giemsa) in use.

LSV.45890 Non-Immunofluorescent Stain QC Phase II

Quality control of all non-immunofluorescent, non-immunologic-based stains (otherthan Gram stains) is performed and recorded with a positive and negative quality controlorganism for intended reactivity each day of use, and for each new batch, lot number andshipment.

Evidence of Compliance:✓ Written procedure for QC of non-immunofluorescent stains

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**REVISED** 09/17/2019LSV.45900 Morphologic Observation Evaluation Phase II

The laboratory evaluates consistency of morphologic observation among personnelperforming Gram, trichrome and other organism stains at least annually.

NOTE: The laboratory must ensure the description of bacteria and other organisms is reportedconsistently amongst all personnel performing the microscopic analysis.


1. Circulation of a pre-graded set of organisms with defined staining characteristics.2. Multi-headed microscopy3. Use of photomicrographs with referee and participant identifications (eg, former CAP

microbiology Surveys or other photomicrographs from teaching collections)4. Use of digital images


Evidence of Compliance:✓ Written procedure defining the method(s) and criteria used for evaluation of consistency AND✓ Records of evaluation

REFERENCES1) Flournoy DJ. Interpreting the sputum gram stain report. Lab Med. 1998;29:763-768

LSV.45910 Fluorescent Stain QC Phase II

Quality control of fluorescent stains is performed for positive and negative reactivity eachtime of use.

Evidence of Compliance:✓ Written procedure QC of fluorescent stain


amendments of 1988; final rule. Fed Register. 2003(Jan 24):7146 [42CFR493. 1256(e)(3); 493.1273(a)]

BIOSAFETY

Items in this section apply to ALL areas of the microbiology laboratory.


● Sampling of biosafety policies and procedures● Sampling of bench top decontamination logs● Records of biological safety cabinet certification

LSV.45912 Bioterrorism Response Plan Phase I

The laboratory is recognized in the institution's bioterrorism response plan and the role ofthe laboratory is outlined in the plan.

Evidence of Compliance:✓ Organizational bioterrorism plan describing the role of the laboratory

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REFERENCES1) Snyder JW. Role of the hospital-based microbiology laboratory in preparation and response to a bioterrorism event. J Clin Microbiol.

January, 20032) Gilchrist MJR. Laboratory Safety, Management, and Diagram of Biological Agents Associated with Bioterrorism

3) Robinson-Dunn B. The microbiology laboratory's role in response to bioterrorism. Arch PatholLab Med. March 2002; 126

4) Morse SA. Bioterrorism: Laboratory Security. Lab Med. June 2001.

LSV.45915 Spill Handling Phase II

There are written policies and procedures for handling spills of contaminated materials.

REFERENCES1) Department of Health and Human Services. Biosafety in Microbiological and Biomedical Laboratories, 5th ed. Washington, DC: HHS

Publishing No. (CDC) 21-1112, December 2009

LSV.45920 Bench Top Decontamination Phase II

There are records of daily decontamination of bench tops.

LSV.45925 Safe Specimen Processing Phase II

There are written policies and procedures for the safe handling and processing ofspecimens.

NOTE: Suggested topics to be considered in the policies and procedures for the safe handlingand processing of specimens include the need for tight sealing of containers, avoiding spillsof hazardous materials, requirements for wearing gloves, the need for respirator protection,availability and use of vaccinations, and the potential hazards of sniffing plates.

REFERENCES1) Jamison R, et al. Laboratory Safety in Clinical Microbiology, Cumitech 29, July 1996, ASM Press; Washington DC

2) Fleming DO, Hunt DL. Biological Safety, Principles and Practices, 3rd ed. ASM Press; Washington DC

LSV.45930 Biosafety Levels Phase II

Policies and procedures have been developed to minimize the occupational risk ofexposure to infectious agents handled in the Microbiology laboratory, in accordancewith current recommendations regarding the biosafety levels for working with differentorganisms.

NOTE: The laboratory director is responsible for the maintenance of precautions in the laboratoryto minimize the risk of personnel infection. Precautions must be appropriate for the types oforganisms tested and the nature of the studies performed.

Each level consists of combinations of equipment, processes and techniques, and laboratorydesign that are appropriate for the type of laboratory and infectious agent handled.


Publishing No. (CDC) 21-1112, December 20092) Richmond J. "Arthropod Borne Diseases", Anthology of Biosafety VI: American Biological Safety Association, Mundelein, IL April

2003

LSV.45940 Biosafety Levels Phase II

Engineering and work practice controls appropriate to the Biosafety level of the laboratoryare defined and implemented.

NOTE: Each increasing BSL number (BSL-1 to BSL-4) implies increased occupational riskfrom exposure to an agent or performance of a process, and therefore is associated with morestringent control and containment practices.

REFERENCES

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1) Department of Health and Human Services. Biosafety in Microbiological and Biomedical Laboratories, 5th ed. Washington, DC: HHSPublishing No. (CDC) 21-1112, December 2009

2) Richmond J. BSL-4 Laboratories. Anthology of Biosafety V: American Biological Safety Association, Mundelein, IL January 2002

3) Richmond J. Biosafety Level 3. Anthology of Biosafety VII: American Biological Safety Association, Mundelein, IL December 2003

LSV.46003 Biological Safety Cabinet Phase II

A biological safety cabinet (BSC) or hood is available for handling specimens ororganisms considered highly contagious by airborne routes.

Evidence of Compliance:✓ Maintenance schedule of BSC function checks AND✓ Records of testing and certification


Publishing No. (CDC) 21-1112, December 2009

LSV.46066 Biological Safety Cabinet Phase II

The biological safety cabinet (BSC) is certified at least annually to ensure that filters arefunctioning properly and that airflow rates meet specifications.

Evidence of Compliance:✓ Maintenance schedule of BSC function checks AND✓ Records of testing and certification

REFERENCES1) NSF/ANSI Standard 49-2012 Biosafety Cabinetry: Design, Construction, Performance and Field Certification. Ann Arbor, MI: NSF;

2012.2) Kruse RH, Puckett WH, Richardson JH. Biological safety cabinetry. Clin Microbiol Rev. 1991;4(2):207-241.

3) Kimman TG, Smit E, Klein MR. Evidence-based biosafety: a review of the principles and effectiveness of microbiological containmentmeasures. Clin Microbiol Rev. 2008;21(3):403-425. doi: 10.1128/CMR.00014-08.

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IMMUNOLOGY SECTION

CALIBRATION AND STANDARDS - NONWAIVED TESTS


● Sampling of calibration and AMR policies and procedures● Sampling of calibration/calibration records● Sampling of AMR verification records● Sampling of patient reports/worksheets for verification of results outside of AMR

● Sampling of calibration materials (quality)


the calibration?● What is your course of action when results fall outside the AMR?

● Further evaluate the responses, corrective actions, and resolutions for unacceptablecalibration, unacceptable calibration verification, and results outside the AMR

The remaining requirements in this checklist on CONTROLS, CALIBRATION, CALIBRATION VERIFICATION,and ANALYTIC MEASUREMET RANGE (AMR) VERIFICATION do not apply to waived tests.

The following requirements for calibration, calibration verification and AMR verification apply only to analysesthat provide truly quantitative measurements expressed in mass units per unit volume (eg, gm/L or mg/ml) ORin units traceable to a reference preparation or standard that is calibrated in mass units per unit volume. If thesecriteria are not met, the measurement is NOT quantitative and this section is not applicable.

NOTE: Explanatory notes and definitions on calibration, calibration verification and analytic measurement rangeverification are found in the Chemistry section of the Limited Service Laboratory Checklist. The master versionof the checklist may be downloaded using e-LAB Solutions on the CAP website.



NOTE: Calibration must be performed following manufacturer's instructions, at minimum,including the number, type, and concentration of calibration materials, frequency of calibration,

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and criteria for acceptable performance. Calibration procedures are typically specified in themanufacturer’s instructions but may also be established by the laboratory.

REFERENCES1) Department of Health and Human Services, Centers for Medicare & Medicaid Services. Clinical laboratory improvement amendments

of 1988; final rule. Fed Register. 1992(Feb 28):7165 [42CFR493.1217]2) Department of Health and Human Services, Centers for Medicare & Medicaid Services. Medicare, Medicaid and CLIA Programs;

Laboratory Requirements Relating to Quality Systems and Certain Personnel Qualifications; final rule. Fed Register. 2003(Jan24):3707 [42CFR493.1255]


4) Miller WG. Quality control. In: Henry's Clinical Diagnostic and Management by Laboratory Methods, 21st Edition, ed McPherson RA,Pincus MR. Saunders Elsevier. 2007;99-111.

**REVISED** 09/17/2019LSV.46075 Calibration and Calibration Verification Materials Phase II


NOTE: Calibration and calibration verification materials must have defined analyte target valuesand appropriate matrix characteristics for the clinical specimens and specific assay method.Many instrument systems require calibration materials with system-specific target values toproduce accurate results for clinical specimens.

Suitable materials for calibration verification include, but are not limited to:

1. Calibrators used to calibrate the analytical system2. Materials provided by the manufacturer for the purpose of calibration verification3. Previously tested unaltered patient/client specimens4. Primary or secondary standards or reference materials with matrix characteristics



Evidence of Compliance:✓ Written policy defining appropriate calibration and calibration verification materials

REFERENCES1) Clinical and Laboratory Standards Institute. Evaluation of Matrix Effects; Approved Guideline. 3rd ed. CLSI Document EP14-A3.

Clinical and Laboratory Standards Institute, Wayne, PA; 20142) Department of Health and Human Services, Centers for Medicare & Medicaid Services. Medicare, Medicaid and CLIA Programs;

Laboratory Requirements Relating to Quality Systems and Certain Personnel Qualifications; final rule. Fed Register. 2003(Jan 24):[42CFR493.1255]


Criteria are established for the frequency of recalibration or calibration verification, andthe acceptability of results.



2. If QC shows an unusual trend or shift or is outside of acceptable limits, and thesystem cannot be corrected to bring control values into the acceptable range

3. After major preventive maintenance or change of a critical instrument component

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4. When recommended by the manufacturer





amendments of 1988; final rule. Fed Register. 2003(Jan 24):3707[42CFR493.1255(b)(3)]2) Miller WG. Quality control. In: Henry's Clinical Diagnostic and Management by Laboratory Methods, 21st Edition, ed McPherson RA,

Pincus MR. Saunders Elsevier. 2007:99-111.




REFERENCES1) Department of Health and Human Services, Centers for Medicare & Medicaid Services. Medicare, Medicaid and CLIA Programs;

Laboratory Requirements Relating to Quality Systems and Certain Personnel Qualifications; final rule. Fed Register. 2003(Jan 24):[42CFR493.1255(a)(3)]


Verification of the analytical measurement range (AMR) is performed with matrix-appropriate materials which, at a minimum, include the low, mid and high range of theAMR, and appropriate acceptance criteria are defined.





4. Patient samples that have reference method assigned target values5. Control materials, if they adequately span the AMR and have method specific target

values.


criteria AND✓ Records of AMR verification at least every six months


amendments of 1988; final rule. Fed Register. 2003(Jan 24):3707 [42CFR493.1255]2) Shah VP, Midha KK, Dighe S, et al. Bioanalytical Method Validation - Pharm Res. 1992;9(4):588–92.

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3) Hartmann C, Smeyers-Verbeke J, Massart DL, McDowall RD. Validation of bioanalytical chromatographic methods. J Pharm BiomedAnal. 1998;17(2):193–218.

4) Findlay JW, et al. Analytical Methods Validation - Bioavailability, Bioequivalence and Pharmacokinetic Studies. Pharm Res.2000;17(12):1551-7.

5) Killeen AA, Long T, Souers R, Styler P, Ventura CB, Klee GG. Verifying Performance Characteristics of Quantitative AnalyticalSystems: Calibration Verification, Linearity, and Analytical Measurement Range. Arch Pathol Lab Med. 2014;138(9): 1773-81.


Verification of the analytical measurement range (AMR) is performed at least every sixmonths and following defined criteria. Records are retained.

NOTE: The AMR must be verified at least every six months after a method is initially placed inservice and if any of the following occur:

1. At changes of reagent lots unless the laboratory can demonstrate that the use ofdifferent lots does not affect the accuracy of patient/client results, and the range usedto report patient/client test data



It is not necessary to independently verify the AMR if the calibration of an assay includescalibrators that span the full range of the AMR, with low, midpoint and high values (ie, threepoints) and the system is calibrated at least every six months. A one-point or two-point calibrationdoes not include all of the necessary points to validate the AMR.

AMR verification is not required for methods that measure an analyte quantitatively or semi-quantitatively, and report a qualitative value based on concentration threshold. For suchmethods, refer to checklist requirement IMM.33905.

Evidence of Compliance:✓ Written policy for AMR verification defining the frequency performed AND✓ Records of AMR verification at least every six months




If a result is greater than or less than the AMR, a numeric result is not reported unless thesample is processed by dilution, a mixing procedure or concentration so that the resultfalls within the AMR.


reported in routine practice. Dilution, a mixing procedure* or concentration of asample may be required to achieve a measured analyte activity or concentration thatfalls within the AMR. The result must be within the AMR before it is mathematicallycorrected by the concentration or dilution factor to obtain a reportable numeric result.


3. All dilutions, whether automatic or manual, should be performed in a way thatensures that the diluted specimen reacts similarly to the original specimen in the

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assay system. For some analytes, demonstrating that more than one dilution ratiosimilarly recovers the elevated concentration may be helpful.

4. This checklist requirement does not apply if the concentration or activity of theanalyte that is outside the AMR is reported as "greater than" or "less than" the limitsof the AMR.



LSV.46105 Quantitative Cut-Off Values Phase II

For qualitative tests that use a quantitative cut-off value to distinguish positive fromnegative results, analytic performance around the cut-off value is verified or establishedinitially, and reverified at least every six months thereafter.

NOTE: This requirement applies to tests that report qualitative results based on a quantitativemeasurement using a threshold (cut-off value) to discriminate between positive and negativeresults for clinical interpretation. It does not apply to methods where the laboratory is not able toaccess the actual numerical value from the instrument.

Appropriate materials for establishment and verification of the cut-off are identical to thoserecommended for calibration verification. The requirement can be satisfied by the process ofcalibration or calibration verification using calibrators or calibration verification materials withvalues near the cut-off. It may also be satisfied by the use of QC materials that are near the cut-off value if those materials are claimed by the method manufacturer to be suitable for verificationof the method's calibration process.

Verification of the cut-off should also be performed at changes of lots of analytically criticalreagents (unless the laboratory director has determined that such changes do not affect the cut-off); after replacement of major instrument components, after major service to the instrument,and when QC materials reflect an unusual trend or shift, or are outside of the laboratory'sacceptable limits, and other means of accessing and correcting unacceptable control values failto identify and correct the problem.

For FDA-cleared or approved tests, the clinical appropriateness of the cut-off value is evaluatedas part of the clinical validation performed by the manufacturer. For laboratory-developed testsand modified FDA-cleared or approved tests refer to COM.40640 for validation of clinical claims.

Evidence of Compliance:✓ Written procedure for initial establishment and verification of the cut-off value AND✓ Records of initial establishment and verification of cut-off value at defined frequency


amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1255].2) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvement

amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1253].



NOTE:

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1. For each analyte, the laboratory procedure defines the maximum dilution that fallswithin the AMR and that can be subsequently corrected by the dilution factor toobtain a reportable numeric result. Note that for some analytes, an acceptabledilution procedure may not exist because dilution would alter the analyte or thematrix causing erroneous results. Also note that, for some analytes, there may be noclinical relevance to reporting a numeric result greater than a stated value.

2. Analytes for which a dilution procedure is unable to bring the activity or concentrationinto the AMR should be reported as "greater than" the highest estimated values.

3. Establishment of allowable dilutions is performed when a method is first placedinto service. The laboratory director is responsible for establishing the maximumallowable dilution of samples that will yield a credible laboratory result for clinical use.

Evidence of Compliance:✓ Patient results or worksheets

CONTROLS - NONWAIVED TESTS


● Quality control policies and procedures● Sampling of QC records

LSV.46205 Calibrators and Controls Phase II

If the laboratory prepares calibrators and controls in-house, these materials are preparedseparately.

NOTE: In general, calibrators should not be used as QC materials. If calibrators are used ascontrols, then different preparations should be used for these two functions.

Evidence of Compliance:✓ Written policy defining criteria for in-house preparation of calibrators and controls

LSV.46215 Calibrators as Controls Phase I

If a calibrator obtained from an outside supplier is used as a control, it is a different lotnumber from that used to calibrate the method.

NOTE: In general, calibrators should not be used as QC materials. However, the practice maybe necessary for some methods when a separate control product is not available. In such cases,the calibrator used as a control must be from a different lot number than that used to calibrate themethod.

Evidence of Compliance:✓ Written policy defining the criteria for the use of calibrators as controls AND✓ QC/calibrator records

LSV.46220 Weakly Reactive Controls Phase II

Reactive, weakly reactive and nonreactive controls are all used in test systems whereresults are reported in that fashion.

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NOTE: Weakly reactive controls must be used when test results are reported in that fashion,unless such controls are not commercially available.


Evidence of Compliance:✓ QC results

ANTI-NUCLEAR ANTIBODY TESTING


● Sampling of ANA result reports

**NEW** 09/17/2019LSV.46240 Anti-Nuclear Antibody Reporting Phase I

The method used for detecting anti-nuclear antibodies (ANA) is included on the report.

NOTE: Indirect immunofluorescence is traditionally used to detect antibodies with affinity forHEp-2 cells, and the pattern of ANA immunofluorescence is reported. Other methods (such asenzyme-linked immunoassay or multiplexed bead immunoassay) may not detect all of the sameautoantibodies as the HEp-2 methodology, and these differences may be clinically significant.The ANA results report must include a brief description of the method used for ANA screening ifthe methodology is not explicit in the test name.

Evidence of Compliance:✓ Records of ANA reports indicating method used

REFERENCES1) Meroni PL, Schur PH. ANA screening: an old test with new recommendations. Ann Rheum Dis. 2010;69:1420-1422.

2) American College of Rheumatology Position Statement: Methodology of Testing for Antinuclear Antibodies. American College ofRheumatology. August 2015.

BLOOD TYPE, GROUP, AND/OR ANTIBODY SCREENS

If the limited service laboratory performs transfusion-related testing or any immunohematology tests otherthan blood group typing (ABO and Rh), antibody screens and direct antiglobulin testing (DAT), the TransfusionMedicine Checklist must be used for inspection.

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● Sampling of blood type/group/antibody screen policies and procedures● Sampling of current package inserts● Sampling of QC records

● Technologist performing testing (recording results at the time of testing)

● What is your laboratory's course of action when ABO and Rh typing results are not inagreement with the patient's historical record?

● How does your laboratory ensure that the direct antiglobulin test detects RBC-boundcomplement as well as IgG?

● How do you confirm negative antiglobulin tests?

● If there had been an instance when the ABO and Rh typing results were not inagreement with the patient's historical record, further evaluate the laboratory'sresponses, corrective actions and resolutions

LSV.46370 Reagent Handling Phase II

Current package inserts for immunohematology reagents are available, and reagents areused according to manufacturer's directions, or if alternative procedures are used, theyhave been evaluated to confirm that they perform as intended.

NOTE: The laboratory must have a procedure that assures that:● The most current package insert is in use● The relevant procedures are updated when changes to the package insert occur

Testing methods used for ABO, Rh and antibody screening that are different from themanufacturer's instructions, are acceptable provided they are not prohibited by the manufacturer,have been demonstrated to be satisfactory, or, for laboratories subject to US regulations, havebeen approved by the Centers for Biologics Evaluation and Research (CBER).

Evidence of Compliance:✓ Written procedures for typing sera/reagents, consistent with manufacturer instructions OR

records of evaluation when procedures have been altered

REFERENCES1) Food and Drug Administration. Guide to inspections of blood banks, Sep 1994

LSV.46450 Antisera/Reagent Red Cell QC Phase II

There are records of acceptable reactivity and specificity of typing sera and reagent redcells on each day of use, including a check against known positive and negative cells orantisera, or manufacturer's instructions for daily quality control are followed.

NOTE: Unless manufacturer instructions state otherwise, the following apply:■ Typing reagents, including antisera (eg, anti-D, anti-K, anti-Fy(a)) and reagent

red cells must be checked for reactivity and specificity on each day of use.

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Typing antisera must be checked with known positive and negative cells; reagentred cells must be checked with known positive and negative antisera.

■ Each cell used for antibody screening must be checked each day of use forreactivity of at least one antigen using antisera of 1+ or greater avidity.

■ Anti-IgG reactivity of antiglobulin reagents may be checked during antibodyscreening and crossmatching.

This checklist requirement can be satisfied by testing one vial of each reagent lot each day oftesting.


amendments of 1988; final rule. Fed Register. 1992(Feb 28):7171 [42 CFR 493.1269]

LSV.46530 Agglutination/Hemolysis Criteria Phase II

Criteria for agglutination and/or hemolysis are defined.

NOTE: Criteria must be defined in the procedure manual to provide uniformity of interpretation ofpositive and negative agglutination and hemolysis results.

LSV.46540 Test Result Recording Phase II

Observations of all test results are recorded properly at the time the test is performed.

NOTE: Test results must be recorded at the time done in order to reduce the risk of transcriptionerrors from delayed recording.

LSV.46560 Anti-D Controls Phase II

Appropriate control(s) are used for anti-D testing.

NOTE: If anti-D reagent contains a potentiating diluent, the appropriate control is the diluentalone.

Evidence of Compliance:✓ Written procedure defining controls used for anti-D testing consistent with manufacturer's

instructions AND✓ Records of anti-D control results

LSV.46565 Historical Record Check Phase II

There is a written procedure to ensure that laboratory records for ABO/Rh testing aresearched for each patient for at least the preceding 12 months.

NOTE: The purpose of this comparison is to detect sample/patient identification errors or othererrors that might lead to the attribution of an incorrect blood type or antibody screen result to apatient. The historical record search can be performed manually by qualified laboratory personnelor with a validated computer system capable of performing historical checks. If the laboratoryperforming the testing does not maintain records that would allow this check to be performed,the testing shall be reported with a disclaimer alerting the ordering physician that the check hasnot been performed and that verifications of the sample's identity and the test results are stronglyrecommended.

Evidence of Compliance:✓ Written procedure for checking ABO/Rh with historical results AND✓ Records of historical checks

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LSV.46570 Typing Discrepancies - Investigation/Reconciliation Phase II

There are records of the investigation and reconciliation of all cases in which ABO and Rhtyping results were not in accord with the patient's historical record.

NOTE: Available laboratory records for each patient must be routinely searched whenever testingis performed. Quality management records must include an investigation of all cases in which theABO or Rh typing was not in accordance with the patient's laboratory historical record.

**NEW** 09/17/2019LSV.46571 Forward/Reverse Typing Phase II

For each patient, red blood cells are tested with anti-A, anti-B, and anti-D, and serum/plasma is tested using A1 and B reagent red cells.

NOTE: The ABO/Rh type of the patient's red blood cells must be determined by an appropriatetest procedure. Tests on each sample must include forward and reverse grouping.

Evidence of Compliance:✓ Written procedure for ABO/Rh typing AND✓ Logs or computer records with forward and reverse grouping


amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1271(a)]

**NEW** 09/17/2019LSV.46572 Unexpected Antibody Screen Phase II

The antibody screen to detect unexpected red cell alloantibodies includes the following:

● Incubation at 37°● Use of red cells that are not pooled● Interpretation at the antiglobulin phase

Evidence of Compliance:✓ Written procedure for screening for unexpected red cell alloantibodies AND✓ Logs or computer records indicating the reactions at the different phases of testing

LSV.46575 DAT Testing Algorithm Phase II

When a direct antiglobulin test is ordered by a patient's physician, the testing algorithmallows for detection of RBC-bound complement as well as IgG.

NOTE: The testing algorithm is intended to detect patients with complement-mediated hemolysiswhich may occur in paroxysmal cold hemoglobinuria, autoimmune hemolytic anemia, or drug-induced hemolytic anemia. Detection of complement is not required for the purpose of diagnosinghemolytic disease of the newborn.

The use of anti-IgG alone will fail to detect some cases of complement-mediated hemolysisbecause not all cases of complement-mediated hemolysis have detectable IgG coating the redblood cell. LSV.46580 and LSV.46583 also apply.

Evidence of Compliance:✓ Written procedure for DAT requiring testing for the detection of RBC-bound complement and

IgG AND✓ Records for DAT consistent with procedure

REFERENCES1) Sokol RJ, et al. Autoimmune haemolysis: an 18-year study of 865 cases referred to a regional transfusion centre. Brit Med J.

1981;282:2023-2027

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2) Packman CH, Leddy JP, Cryopathic hemolytic syndromes. In: Beutler E, et al, eds. William's Hematology, 5th ed. New York:McGraw-Hill, 1995:685-691

3) Vengelen-Tyler V, ed. American Association of Blood Banks Technical Manual, 13th ed. Bethesda, MD: AABB Press, 1999:259-262

LSV.46580 Direct Antiglobulin Testing Controls Phase II

When performing an antiglobulin test with anti-IgG or polyspecific antiglobulin reagents,IgG-coated red blood cells are used as a control in all negative antiglobulin tests.

NOTE: IgG-coated red blood cells must be used to confirm all negative antiglobulin tests whenthe antiglobulin reagent used for testing has anti-IgG reactivity. Tests found negative by tubemethodology must be verified by obtaining a positive test result after adding IgG-coated (control)red blood cells. If a licensed system is used that does not require verification of negative testresults using IgG-coated cells, an appropriate quality control procedure must be followed, asrecommended by the manufacturer.

Evidence of Compliance:✓ Records of testing that include control results confirming negative antiglobulin tests

LSV.46583 Direct Antiglobulin Testing Phase II

When performing an antiglobulin test with anti-C3 antiglobulin reagents, C3-coated redblood cells are used as a control in all negative antiglobulin tests.

NOTE: Complement-coated red blood cells must be used to confirm all negative antiglobulintests when the antiglobulin reagent used for testing has anti-C3 reactivity. Tests found negativeby tube methodology must be verified by obtaining a positive test result after adding C3-coated(control) red blood cells. If a licensed system is used that does not require verification of negativetest results using C3-coated cells, an appropriate quality control procedure must be followed,as recommended by the manufacturer. If a polyspecific antiglobulin reagent is used, refer tochecklist item LSV.46580.

Evidence of Compliance:✓ Written procedure for confirming negative antiglobulin tests with anti-C3 reagent for

applicable method AND✓ Records of testing that include control results confirming negative antiglobulin tests

SYPHILIS SEROLOGY


● Sampling of syphilis serology policies and procedures● Sampling of QC records● Needle delivery volume logs

● What is your laboratory's course of action prior to performing RPR, VDRL, TPPA,and/or USR patient testing using new antigen reagent lots?

LSV.46587 RPR Needles Phase II

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If antigen is delivered by needles, the volume of delivery is checked under each of thefollowing circumstances.

1. Each time a new needle is used2. When control patterns cannot be reproduced3. When the antigen drop does not fall cleanly from the tip

Evidence of Compliance:✓ Written procedure for RPR needle verification AND✓ Records of needle verification

REFERENCES1) Larsen SA, Pope V, Johnson RE, Kennedy EJ Jr, eds. Manual of Tests for Syphilis. Washington, DC. Amer Public Health Assn:

1998.

LSV.46594 Syphilis Serology Controls Phase II

A negative control, plus positive serum controls of known titer or controls of gradedreactivity are run each day of patient testing.

NOTE: A negative control plus positive serum controls of known titer must be run each day ofpatient testing. If the laboratory reports graded patient results, then graded controls must be run.

Evidence of Compliance:✓ QC results


amendments of 1988; final rule. Fed Register. 2003(Jan 24):3708 [42 CFR 493.1256(d)(3)]

LSV.46601 New Reagent Lot Confirmation of Acceptability - RPR, TPPA and VDRL Phase II

New reagent lots of antigen for RPR, TPPA, and VDRL tests are checked in parallel withthe existing lot to confirm appropriate levels of reactivity.

NOTE: Because the ability of a reagent to detect specimens with low-grade reactivity isnecessary for the diagnosis of primary syphilis, new reagent lots should be checked with samples(either patient samples or controls) with graded reactivity. At least one low-grade sample, inaddition to negative and positive should be used.

Evidence of Compliance:✓ Written procedure for confirmation of acceptability of new antigen lots prior to use AND✓ Records of verification data of new lots

REFERENCES1) Kennedy EJ, et al. Quality Control. In, SA Larsen et al (eds). A manual of tests for syphilis, 9th ed. Washington, DC: American Public

Health Association, 1998; chap 4

LSV.46605 Anti-Treponemal Antibody Screening Phase II

If the laboratory uses anti-treponemal antibody testing as a screening test for syphilisinfection, confirmation of positive results includes a non-treponemal test (eg, RPR).

NOTE: Anti-treponemal antibody testing has been shown to be an effective way to screen forinfection with Treponema pallidum. Negative results indicate that syphilis is unlikely. Becauseanti-treponemal antibodies persist after treated infection, guidelines recommend performing thenon-treponemal RPR test to determine if infection is current or past. Also, the RPR is the assaythat should be used to monitor treatment of acute infection.

Evidence of Compliance:✓ Written procedure for confirmation of anti-treponemal antibody results with RPR AND✓ Records of RPR confirmation of positive anti-treponemal antibody results

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REFERENCES1) Workowski KA, Bolan GA. Sexually transmitted disease guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-37.

2) Rhoads DD, et al. Prevalence of traditional and reverse-algorithm syphilis screening in laboratory practice. A survey of participants inthe College of American Pathologists syphilis serology proficiency testing program. Arch Pathol Lab Med. 2017;141(1):93-97.

HIV PRIMARY DIAGNOSTIC TESTING - IMMUNOLOGY


● Sampling of HIV diagnostic testing policies and procedures● Sampling of HIV result reports

**NEW** 06/04/2020LSV.47050 HIV Primary Diagnostic Testing - Supplemental and Confirmatory Testing Phase I

The laboratory follows public health recommendations or guidelines for HIV primarydiagnostic testing, including primary screening and additional (supplemental and/orconfirmatory) testing.

NOTE: If additional testing after a primary screening test is recommended by public healthauthorities, the laboratory:

● Performs additional testing reflexively if the specimen is suitable and the test isperformed in house, or

● Sends additional testing to a referral laboratory if the specimen is suitable, or● Provides guidance to providers on submission of additional specimens, if needed

for supplemental or confirmatory testing.

The US Centers for Disease Control and Prevention (CDC) and Association of Public HealthLaboratories (APHL) provide recommendations for HIV testing. Guidelines and recommendedalgorithms can be found on the CDC and APHL websites.

This checklist item does not apply to the testing of individuals from whom human derivedproducts for therapeutic use are being derived or other types of testing performed for themonitoring of HIV infection (eg, viral load, CD4 counts). Reporting HIV results to public health isnot within the scope of this checklist item.

Evidence of Compliance:✓ Written policy for the performance of HIV testing AND✓ Patient reports with initial screening results and reflexive testing results and/or guidance

REFERENCES1) Centers for Disease Control and Prevention and Association of Public Health Laboratories. Laboratory Testing for the Diagnosis of

HIV Infection: Updated Recommendations. Available at http://stacks.cdc.gov/view/cdc/23447. Published June 27, 2014. Accessed11/19/2019.

2) Association of Public Health Laboratories. Suggested Reporting Language for the HIV Laboratory Diagnostic Testing Algorithm.January 2019. Available at APHL Publications. Accessed 11/19/2019.

https://www.cdc.gov/hiv/guidelines/testing.html

https://www.aphl.org/programs/infectious_disease/Pages/HIV.aspx

http://stacks.cdc.gov/view/cdc/23447

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DIRECT ANTIGEN TESTING


● Sampling of direct antigen testing policies and procedures● Sampling of QC records

LSV.48410 Direct Antigen Test QC Phase II

For nonwaived direct antigen tests on patient specimens, positive and negative controlsare tested and recorded at least daily, or more frequently if specified in the manufacturer'sinstructions, laboratory procedure or the CAP Checklist.

NOTE: This requirement pertains to nonwaived tests with a protein, enzyme, or toxin whichacts as an antigen. Examples include, but are not limited to: Group A Streptococcus antigen, C.difficile toxin, fecal lactoferrin and immunochemical occult blood tests. For panels or batteries,controls must be employed for each antigen sought in patient specimens.


For each test system that requires an antigen extraction phase, as defined by the manufacturer,the system must be checked with an appropriate positive control that will detect problems inthe extraction process. If an IQCP is implemented for the test, the laboratory's quality controlplan must define how the extraction phase will be monitored, as applicable, based on the riskassessment performed by the laboratory and the manufacturer's instructions.

Evidence of Compliance:✓ Written QC procedures AND✓ Records of QC results including external and internal control processes AND✓ Manufacturer product insert or manual

LSV.48430 Group A Streptococcus Direct Antigen Detection Phase I

If group A Streptococcus direct antigen testing is performed on pediatric patients,confirmatory testing is performed on negative samples.

NOTE 1: Policies must be established for the use of cultures or other confirmatory testson pediatric specimens that test negative when using antigen detection methods or if themanufacturer's guidelines include recommendations for culture follow-up. These policies shouldtake into account the sensitivity of the assay in use, the age and clinical presentation of thepatient, and other factors.

NOTE 2: Direct antigen tests should be performed and reported in a timely fashion, since theirprincipal advantage (compared culture) is rapid turn-around-time.

REFERENCES1) Shulman S, Bisno A, Clegg H, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal

Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10). doi: 10.1093/cid/cis629.

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LSV.48440 Clostridioides (Formerly Clostridium) difficile Phase II

There are written policies for the testing of stool for the detection and reporting of C.difficile or its toxins.

REFERENCES1) Noval-Weekley SM, et al. Clostridium difficile testing in the Clinical Laboratory by Use of Multiple Testing Algorithms. Journal of

Clinical Microbiology 2010; 48:889-8932) Eastwood K, et al. Comparison of Nine Commercially Available Clostridium difficile Toxin Detection Assays, a Real-Time PCR Assay

for C. difficile tcdB and a Glutamate Dehydrogenase Detection Assay to Cytotoxin Testing and Cytotoxigenic Culture Methods.Journal of Clinical Microbiology 2009; 47:3211-3217

3) Peterson LR and Robicsek A. Does my Patient have Clostridium difficile Infection? Annals of Internal Medicine 2009; 151:176-178

LSV.48450 CSF Back-Up Cultures Phase II

If bacterial antigen-detection methods are used, back-up cultures are performed on bothpositive and negative CSF specimens.

NOTE: Total dependence on a bacterial antigen test for the diagnosis of bacterial meningitisdoes NOT meet accreditation requirements. Meningitis may be caused by bacteria not detectedby the antigen tests. In addition, it is important to recover the causative agent for susceptibilitytesting. Thus, culture is essential for proper evaluation of bacterial meningitis, and must beperformed on the patient specimen - if not performed onsite by the laboratory, the inspector mustseek evidence that a culture has been performed in a referral laboratory.

Evidence of Compliance:✓ Written policy that CSF cultures are performed in conjunction with bacterial antigen tests OR

policy requiring testing at another location AND✓ Records of back-up CSF cultures performed on-site OR records indicating that cultures are

performed at another location OR records that order for CSF bacterial antigen was blockedby the computer due to no order for a culture

REFERENCES1) Forward KR. Prospective evaluation of bacterial antigen detection in cerebral spinal fluid in the diagnosis of bacterial meningitis in a

predominantly adult hospital. Diagn Micro Infect Dis. 1988;11:61-632) Maxson S, et al. Clinical usefulness of cerebrospinal fluid bacterial antigen studies. J Pediat. 1994; 125:235-238

3) Finlay FO, et al. Latex agglutination testing in bacterial meningitis. Arch Dis Child. 1995;73:160-161

4) Rathore MH, et al. Latex particle agglutination tests on the cerebrospinal fluid. A reappraisal. J Florida Med Assoc. 1995;82:21-23

5) Kiska DL, et al. Quality assurance study of bacterial antigen testing of cerebrospinal fluid. J Clin Micro. 1995;33:1141-1144

LSV.48460 Cryptococcal Antigen Phase II

If cryptococcal antigen-detection methods are used on CSF, back-up cultures areperformed on positive CSF specimens submitted for diagnosis.

NOTE: It is important to recover the causative organism for precise identification (C. neoformansvs. C. gattii) and potentially susceptibility testing. Back-up cultures of follow-up specimens usedfor trending the antigen titer are not required. If culture is not performed onsite by the laboratory,the laboratory must show evidence that it has been performed in a referral laboratory.

Evidence of Compliance:✓ Written policy that CSF cultures are performed in conjunction with initial cryptococcal antigen

tests OR policy requiring testing at another location AND✓ Records of back-up CSF cultures performed on-site OR records indicating that cultures are

performed at another location

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MOLECULAR-BASED MICROBIOLOGY TESTING - WAIVED TESTING

The requirements in this section apply to molecular-based microbiology tests classified as waived performedin a limited service laboratory setting. Microbiology testing performed by nonwaived molecular-based methodsmust be inspected with the Microbiology Checklist.


● Sampling of QC statistics● Sampling of molecular microbiology specimen handling and processing policies and

procedures● Sampling test reports (test methodology, clinical interpretation)

● What is your course of action when monitored statistics increase above the expectedpositive rate?

**NEW** 09/17/2019LSV.48475 Quality Monitoring Statistics Phase I

There are written procedures to monitor for the presence of false positive results (eg, dueto nucleic acid contamination) for all molecular microbiology tests.

NOTE: Examples of this may include review of summary statistics (eg, monitoring percentage ofpositive results relative to current local and regional rates and increased positive Strep resultsabove historical rate within a run or over multiple runs), performance of wipe (environmental)testing, review and investigation of physician inquiries, and use of process controls to minimizerisk of contamination.

Evidence of Compliance:✓ Written procedure for monitoring for presence of false-positive results AND✓ Records of data review, wipe testing, statistical data evaluation and corrective action if

indicated

REFERENCES1) Borst A, Box AT, Fluit AC. False-positive results and contamination in nucleic acid amplification assays: suggestions for a prevent

and destroy strategy. Eur J Clin Microbiol Infect Dis. 2004; 23(4):289-99.2) Cone RW, Hobson AC, Huang ML, Fairfax MR. Polymerase chain reaction decontamination: the wipe test. Lancet.1990; 336:686–

687.3) McCormack JM, Sherman ML, Maurer DH. Quality control for DNA contamination in laboratories using PCR- based class II HLA

typing methods. Hum Immunol. 1997;54:82–88.4) Clinical and Laboratory Standards Institute (CLSI). Establishing Molecular Testing in Clinical Laboratory Environments; 1st ed. CLSI

document MM19-A. Clinical and Laboratory Standards Institute, Wayne, Pennsylvania, 2011.

**NEW** 09/17/2019LSV.48485 Specimen Handling Procedures Phase II

There are written procedures to prevent specimen loss, alteration, or contaminationduring collection, transport, processing and storage.

NOTE: Specimen collection, processing and storage must follow manufacturer's instruction andlimit the risk of preanalytical error. For example, there must be a procedure to ensure absence ofcross-contamination of samples during processing/testing for respiratory specimens that may besent for further testing.

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It is also essential to follow the manufacturer’s instructions for the handling of wastes (eg, usedtest cartridges) to prevent contamination.

**NEW** 09/17/2019LSV.48495 Safe Specimen Handling/Processing Phase II

There are written policies for the safe handling and processing of samples from patientswith suspected infections due to avian influenza, SARS, Ebola, or similar emergingpathogens.

**NEW** 09/17/2019LSV.48505 Final Report Phase I

The final report includes a summary of the test method and information regarding clinicalinterpretation if appropriate.

NOTE: For tests that may be performed by either direct antigen or molecular-based methods(PCR), including the test method in the report is important for interpretation of the results. Thereport must include a brief description of the method if the methodology is not explicit in the testname.

master laboratory checklist limited service

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