TITLE: Hematology – CBC/Diff Resulting in the LIS

PRINCIPLE:

To provide guidance and instructions to staff for resulting the CBCDF and HGDFS in

Caresphere.

INTENDED USE

Caresphere Workflow Solutions (WS) is a software application intended for use as a calculator/data processing system inclusive of hardware and software components. Caresphere WS provides data transfers, format conversions and electronic storage retrieval functions as well as connectivity between laboratory instruments and laboratory information systems. It also displays data such as scattergrams, histograms, analyzer flags and reportable numerical data from connected devices. Caresphere WS is intended to be used by trained laboratory personnel to aid in the management of laboratory results, laboratory instrument interfacing and data management.

PERSONNEL:

Medical Technologists, Medical Technicians.

STEPWISE PROCEDURE:

1.	Results will cross the instrument interfaces from the Sysmex XN-9100. We will see them in Caresphere.

To log into Caresphere, click the Caresphere link on computer main screen.

Your Username is your email address (ie. Someone@rush.edu)

Click log in or hit enter key

An incognito screen will appear. Click the Caresphere link in the upper left side under web address line.

Your User name is your RUMC user name. The Password is your email password.

Caresphere main screen should pop up.

2.	Result Validation

From the Caresphere WS homepage screen, select the To Be Validated panel.

NOTE: The default setting for the To Be Validated panel is to allow only those Sample IDs with results that are Pending, Rerun or To Be Validated.

The Result Validation screen will display qualifying Sample IDs and results for selection and review.

Sample List

Sample IDs are displayed at the far right of the screen, in priority order.

Sample IDs with critical results and sample IDs ordered STAT will

be prioritized to the top of the Sample List.

Sample IDs appear in alphanumeric order within each category.

Unregistered samples do not have an order from the LIS but have results. All Unregistered Sample IDs with pending orders will remain on the list until the order is validated or cancelled by the user. Unregistered Sample IDs will be prioritized to the bottom of the Sample list.

The software performs a default scan of the database every 30 seconds to refresh the Sample List by adding new samples and removing fully validated samples.

Result Color Coding

Results are color-coded to indicate their status

Value	Background Color	Letter Color
Critical Low	Blue Background	Yellow Letters
Critical High	Red Background	Yellow Letters
Delta Values	Lime Green Bkgd.	Blue Letters
Other	Can be configured by Administrator	Can be configured by Administrator.

The two sections we will be using in Caresphere are the To Validate and Fluid Sections.

Select Sample for Processing:

Select a Sample ID from the sample list by clicking on the specific Sample ID. Use scroll bar to view additional Sample IDs.

Review the Operator Alerts:

Left side of the screen contains Operator Alerts containing site specific instructions to process the specimen.

As results are available they will be displayed in the To Validate section. They appear in the Sample List down the right side of the screen. Click on the line with the “Order Number” you are starting with and review the displayed results. ONLY results that need attention will be in the To Validate section. Normal results and results with H or L flags will auto verify from the analyzers. Click on order number to open.

3.	Patient Demographics are at the top of the screen.

4.	Op Alerts (the reason the sample is being held) will be at the left side of the screen.

5.	Results for the sample will be at the center of the screen. If the sample was rerun and any previous results will be next to current result.

6.	Actions to be taken will be towards the right side of the screen under the Manual box.

7.	A list of specimens that are not verified will be at the far right side of the screen.

8.	Check Unregistered Samples in Soft OE. If needed, log in sample.

9.	To remove an Unregistered Sample from the Sample list click on the Sample ID, click the detail button at the bottom left of the To Validate scree., From the pop up list click the Cancel Order button and check the appropriate reason. This will remove the Sample from the Sample list but will not cancel it in Soft.

10.	If Caresphere did not order a rerun on the sample and you feel it needs a rerun you can order one by clicking on the Actions button at the bottom left under Op Alerts. From the list that pops up click Rerun. This will shift the original results over and leave a blank spot for the new rerun results. Put the specimen back on the line and the XN will rerun the specimen.

To choose which run you would like to Validate, click the two blue arrows next to Rerun.

This will open a screen that will allow you to choose which run you want. Click save.

11.	You can also add a Buffy coat Smear to a sample with the Actions button. Press the Actions tab. From the pop-up list click Add Test. From the list of tests, scroll to Buffy. Check the box in front of the word Buffy and click Save. The word buffy should then be in the manual box under Neutrophil and/or Smear 1. Check the box in front of buffy. Click on the ellipsis and choose performed. This will send an order to Soft for your buffy coat slides.

12.	Review results – compare to previous results. To check previous results click on the blue arrow next to Previous results. This will bring up the past 5 results run on the analyzer. Make sure results “make sense”. Call all criticals. Once review is complete and if there are no actions to be taken in the Manual box, the CBC can be validated by clicking the Validate All button at the bottom of the screen. OR you can partial post by clicking Validate CBC. This validates the Hemogram portion of the CBC, not the differential. You can then move onto Morphology or Manual differential.

12.	If the specimen has a critical result, a critical call box will open when you Validate the results.

Enter the name of the nurse/doctor you spoke to, click the read back box and save.

13.	Under Manual box there are 2 options:

a.	Smear 1 (or Smear 2) – this means either 1 or 2 slides were made by the slide stainer. The slide should be reviewed for abnormal morphology and /or abnormal WBC’s. If nothing abnormal is observed, click the morphology tab (under Manual). You must answer PLT estimate (your options are checked, marked increased, marked decreased). If PLT morphology is abnormal (Giant) click the ellipsis in the Platelet morphology line and choose G for Giant. RBC morphology must also be answered (your options are normal or present). If you choose present then enter the abnormal morphology that is present on the slide. For WBC scan requirement, review slide. If nothing abnormal is observed you do not need to do a diff. Click on ellipsis next to the word Smear and check the appropriate reviewed box.

b.	If the word Neutrophil is in the Manual box, it means a manual diff is required. Click on the diff tab (above the word Neutrophil). Your diff pad will open.

After counting 100 cells, click the save button at bottom right of screen. If you feel a second 100 cell count is warranted, click the Count 2 button. This will let you count a second 100 cells. When you click Save, a box will pop up asking if you would like to put through Count 1, Count 2 or the Average. Click Save.

Remember, every manual diff gets morphology. When you click Save, you will be taken back to the Sample Explorer screen. Click the Morph tab in the Manual box and complete Morphology.

c.	When Morphology is complete and saved, it should take you back to the Sample Explorer screen. Make sure all results from your manual diff and /or morphology are on the Validate screen under the Manual box

Click Validate all. The specimen should now be removed from your specimen list. Go on to the next specimen for review.

14.	Based on our Lean Diff Criteria, using the decision making rules built in Caresphere, the manual differential criteria and the RBC parameter criteria, rules are set to fire when a manual differential or slide review is needed. Most of the rules mimic what has been built into the analyzers and our policies. When a slide is required, the sample will advance to the Sysmex SP-50 stainer and a slide will automatically be made and stained.

15.	Repeat all first time critical results, delta checks or questionable results on the other analyzer as needed, as per protocol.

16.	Review all flags and take appropriate action before posting anything.

17.	The HGDFS (Hemogram Diff) still exists and we have it built like the CBCDF, but the rules do not fire for the location ONCOP. We don’t want to do manual differentials on those 99% of the time, so we can post all if the results are similar to previous. The instrument flags or errors will stop the results from auto verifying, review results in the Result Validation screen in Caresphere. Because it is from Oncology we will be reporting the ADIFF.

Click on the box next to the test that you wish to delete (ex. NEUT) in the Manual box.

Select Details button (lower left side of the screen).

Select “Remove Test” option.

A box will pop up asking “Are you sure you want to delete selected record(s)? Click yes.

This should remove the manual differential and allow you to just result out the ADIFF by selecting Validate All and reviewing/canceling the smear. If you need to add a Manual Diff, click the Diff button, complete diff and morphology and Save. Caresphere will generate the order for you in Soft.

18.	First time WBC counts <0.5 will have a buffy coat smear performed. Subsequent CBC’s

will have the automated differential reported out until the WBC count is equal to or greater than 0.5. Click on the blue comment box next to the WBC count, click on Add coded comment at the bottom of the comment box. Click on COPLWBC. This will add the canned comment “WBC count to too low for precise manual differential to be performed.” To cancel NEUT, see above step 17.

19.	Hematology is NOT black and white. If you think there should be a differential done and it is not in the Manual Box, add a Manual Diff by clicking the Diff button.

20.	If results are similar to previous and a manual differential or slide review have been done within 24 hours, results can be verified and MDIFF or slide review can be cancelled in Caresphere.

MANUAL DIFFERENTIALS:

You will be performing the MDIFF’s and Morph or Platelet review in Caresphere in the Validate screen. After reviewing Op Alerts to see why specimen was held, check the Manual portion on the Validation screen to see what is required to complete the specimen.

If Smear 1 is listed you need to review the slide. Smear 1 is triggered for various flags including platelet flags, if the Platelet count is less than 50 or greater than 1000, the HGB is less than 6.0 (adults) or less than 7.0 (babies) or there are certain NRBC flags. You are required to enter results for both PLT estimate and RBC morphology for morph to cross to Soft. To enter Morphology click the Morph button in the Manual box section.

The three dots (ellipsis) have canned messages that can be added or you can add a free text message by clicking the blue boxed under comment. (Canned messages can also be added in the comment section).

If, upon review of the slide, you feel a manual diff is indicated, click the Diff key (in manual box) and complete the manual diff. As long as the CBC has only been partial posted (Validate CBC button Clicked) no results will be affected by adding a manual diff at this point.

If Neutrophil is present in the Manual area, a manual diff is required. This will be triggered if there are blast flags, IG >5%, Lymphs >60%, Monos >20%, Eos >20%, Basos >5%, NRBC >5%, all babies <30 days old, Critical Abs # Neutrophils. To perform a Manual diff in Caresphere click the Diff button in the Manual box. This will open your diff pad.

In the upper left hand corner are:

The number of cells you have counted on the differential.

A tab you can use to subtract a cell (be sure to click back on add)

A second count pad if you feel a second count on the same slide is warranted. If you do 2 seperate 100 cell diff., When you click Save, a box will pop up that asks if you want to save Count 1, Count 2 or the average of both diffs.

You can change the number of cells counted in the diff. (If WBC count is very low etc)

Count 100 cells (or appropriate number for WBC count). Add any diff comments

Upon completion of your count, you can add a canned message to your diff by clicking on the ellipsis next to the cell number. You can add a free text or canned message by clicking on the blue boxes under the Com heading.

Click the Save button. Return to the Sample explorer screen.

Make sure Morphology and Platelet Estimate has also been completed and is present on the Sample explorer screen with your differential results.

If all results are there, Validate All. Your results should leave the screen and the test number should be removed from the Sample List at the Right of the screen.

Our review of abnormal smears has not changed, leave them for review by Senior tech or designee.

If a Pathologist Smear review is requested/required, go to the same CBC order number and add SMEAR. We will result in Soft with ‘See Text’ and free text in the pathologist remarks.