world veterinary congress presentation
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Determination of acceptable levels of haemolysis when accepting blood samples for trace mineral analysis
Bronwyn Claudia Cloete
The effect of haemolysis on the quality of results in the Biochemistry laboratory
It’s all about Quality“A process is a collection of activities
that converts inputs into outputsor results” - Gryna, Chua & DeFeo (2007:195)
A collection of processes is asystem
ISO 9001:2008 advocates the Process Approach
Coffee Making Process:
Specific requirement: Morning CuppaSpecific inputsSpecific stepsEvaluate outcomeDetermine improvement needsImprove
QUALITY IS APPLICABLE TO EVERYTHING
ISO 9001:2008What the customer wants is what the
customer getsProcess Approach:
Inputs Outputs
Based on customer requirementsWithout customer, there will be no need for
QualityOverview of ISO 9001:2008
PROCESS
SANS 17025: 2005
Identical implementation to ISO/IEC 17025:2005
Overview of ISO 17025:2005ISO/IEC 17025:2005 is based on ISO 9001No compliance to ISO/IEC 17025 without
compliance to ISO 9001New standard due soon
Improvement = Object of StudyQuality Improvement needs to add practical
value
Research Design: Primarily scientific with elements of social science methodology
Structure of research design: Action research in the positivistic paradigm
Experimentation for data collectionProtocol analysis and Observation data
collectionAu fait with study environment
Indentify Customer Requirements
Research Objective: Determine exact values of acceptable levels of haemolysis when accepting blood samples for trace mineral analysis.
Primary Research Question: What is the maximum haemolysis level acceptable, as measured in terms of optical density using a spectrophotometer at 540 nm wavelength, in order to accept samples for Trace mineral analysis?
Literature Review Saibaba (1998: online) states presence of substance in a sample having effect which changes correct value of the
result must be corrected to ensure quality (Saibaba, 1998: online) Thomas (2010: online) contends that haemolysis is an important interference factor (Thomas, 2010: online) Guder. (1986: online) asserts: “Haemolysis is defined as the breakdown of red blood cells and the release of
haemoglobin and intracellular contents into the plasma and Plasma concentrations exceeding 300mg/L, results in the haemolysis of red blood cells being observable to the naked eye. (Gruder, 1986: online)
Lippi, (2009: online) states major worldwide concern for all clinical laboratories is in vitro haemolysis affecting test results and seriously impacts on patient care and the laboratory’s reputation. (Lippi, 2009: online)
Ong, Chan, Lim (2009: online) conducted studies finding that a cost saving occurred with a reduction in sample hemolysis (Ong et al., 2009: online)
Henry, Cannon, and Winkelman, asserts that Spectrophotomic methods can be used to read hemoglobin levels. (Henry et al., 1974 (6))
Spectrophotometers are standard research tools, used in chemistry laboratories, utilizing the relationship absorption of light and colour as principle for the way it works. (Hoydt, n.d.: online)
To achieve impact from research, the research environment is examined from holistic perspective. Ruiz-Marrero (2009: online) contends the holistic view, is an “interdisciplinary vision conceiving every natural system as an integrated whole, which cannot be understood if broken down into its constituent components” (Ruiz-Marrero, 2009: online)
In additional to holistic consideration the research environment Jiju Mike, Andreas, (1998: 169 - 176) contends the use of statistical quality control techniques is an essential part of the search for effective quality control and can lead to quality improvement id applied correctly. (Jiju et al, 1998: 169 - 176)
According to The Quality Assurance Project,(QAP), (n.d.: online) quality improvement involves applying methods most appropriate in order to close the gap between expected levels of quality and current levels of quality.
Gate to Quality (n.d.: online) asserts that “Any tool or technique that can be used for improving the process/product quality, help in analyzing the current situation, help in gathering information or help in bringing small or big change (towards improvement) in the organization can be called a Quality tool or technique.” (Gate to Quality, n.d.: online)
Identify and Examine ProcessQuality engineer’s toolbox7 Basic Quality Tools (B7)
PDCA cycleAdditional: 7 New Quality Tools for project
management (N7)
Plan Phase : Background ResearchBased on research objective the following were
examined in the research environment:
QMSEquipment resourcesReagents and methodsStaff componentOther Process Inputs: Samples
Ishikawa Root Cause Analysis
Ishikawa Diagram
Sample pie chart
Existing Process MapQuality Management SystemAll systems in Biochemistry
Reception: Samples arrive at LabSample information captured
Sample Analysis:Verifiable analytic method according to SOP.
Controlled conditionsUse of Controls and Standards
Critical Suppliers
Quality Management Documents and Records
Satisfied Service Customer
Technologist reviews resultIssues it for release from Biochem
Validation: Checks performed to see if SOP followedControls and Standards in spec
Veterinarian reviewsCompiles with results from other labs
Issues report
Samples delivered to Biochemistry Section
Sample Reception at BiochemistrySamples information recorded.
Biochemistry lab number assigned.Test Allocation.
Samples stored under ideal conditions until testing
Record keeping
YES
NO: Corrective action involves
redo
PDCA Cycle
PLAN, DO, CHECK and ACTCycles for continuous improvementAlso known as PLAN, DO, STUDY and ACT
(PDSA)
Dr William Edwards Deming1900 - 1993
Statistician, professor and authorConsidered the Father of QualityRenowned for work conducted post
World War II and credited for the “Japanese Industrial Miracle”
Along with Juran, launched Total Quality Management
“Learning is not compulsory ...neither is survival “ – Dr. William E. Deming
Do Phase : Conduct an Experiment
Sample group of ten ewes, nonpurposively sampled.
Four samples of blood collected in red top serum tubes from each ewe on fortnightly basis.
One tube from each animal centrifuged immediately, serum removed from clot.
Artificial manipulation remaining three tubes, blood stored in 25oC incubator and every third day a tube was centrifuged and serum removed.
Samples stored in 4oC fridge until analysis.
Do Phase : Conduct an Experiment
Procedure repeated for ten replicates over a twenty week period.
Thus: Ten sets of data collected for each animal in the sample group.
All samples were spectrophotometrically measured.Each data set contained measurements of the
following trace elements: Cu, Zn, Ca, Mg, Phos and Fe.
Measurements were taken of Fresh samples, Day three, Day six and Day nine samples.
Check Phase : Analyse the dataRaw data analysed with statistical quality
tools
SPC : Control charts, ANOVA hypothesis testing and regression and correlation
Check sheets, scatter diagrams
CUSTOMISE THE BOUQUET OF QUALITY TOOLS FOR YOUR OWN PURPOSE
Average Spectrophotometric Measurements
103 104 114 117 119 120 123 124 129 1410
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Average Haemolysis Readings
Fresh Day 3 Day 6 Day 9
Fresh Day 3 Day 6 Day 90
0.2
0.4
0.6
0.8
1
1.2
Average Haemo-lysis Readings
Series1
Copper (Cu)
Mean copper mineral levels were significantly out of recommended normal range, as expected due to known environmental factor of soil copper levels in the Stellenbosch area being traditionally low. Copper levels were elevated with the upward progression of haemolysis in samples. This elevation was detrimental to result quality output even though it was within recommended normal range.
Zinc (Zn)
Mean zinc mineral levels stayed within recommended normal range, however a trend was observed whereby the mean zinc levels were elevated due the upward progression of haemolysis levels. Thus it can be said that uncontrolled haemolysis in samples would have a detrimental effect to result quality output.
Calcium (Ca)
Mean calcium trace mineral levels were initially found to be within the recommended normal range, however with the upward progression of haemolysis, the mean calcium levels were found to significantly decrease. Thus uncontrolled haemolysis in samples would have a detrimental effect to result quality output. Group 9 mean calcium levels were out of recommended normal range.
Manganese (Mg)
Mean magnesium trace mineral levels stayed within recommended normal range, however an upward trend was detected in relation to the upward progression of haemolysis.
Phosphorous (Phos)
The mean phosphorous trace mineral level s of the fresh group was found to be within recommended normal range, however with the upward progression of haemolysis the mean trace mineral value steadily moved upwards and significantly out of recommended normal range.
Iron (Fe)
The mean iron trace mineral level of the fresh group was only slightly out of recommended normal range. It was determined that this could also be as a result of environmental factor impacting on research, however the significant observation to be made during interpretation, is considered to be the steady and marked upward trend of mean iron levels with the upward progression of haemolysis occurrence in samples. Mean iron levels of groups Day 3, 6 and 9 are considered to be significantly out of recommended normal range.
ANOVA and Questionnaire Analysis
With the exception of the trace element Zn an ANOVA f test conducted tested the hypothesis that the haemolysis effect on the results of all the other trace element was significantly different.
Protocol analysis and observation studies were conducted. Statistical analysis of feedback from staff members provided a scale for a colour chart.
Quality Improvement AreasSeptember 22,
2010
Page 1
Chart Type
Survey Sample - 8 Categories
Operational Systems in Biochemistry Environment
100
90
80
70
60
50
40
30
20
10
LegendPre-analytical
FactorsEquipment
Factors
Process Factors External Factors
Support Requirements Defined: Documentation and Records
Process Structure: Logical, sequential,
comprehensive
Process Requirements Defined: Documentation and Records
Corrective Action/
Preventative Measure in
system
Control Measures in system
Traceabilty and adequate Identification of samples in system
Calibration in system
Effectivity
Notes:
This chart illustrates the results of protocol analysis on the operational environment of biochemistry laboratory in relation to the various systems which comprise of it namely:
· Pre-analytical Systems· Core Process Systems· Equipment Factor Systems· External Systems input
A graphic representation is given, enabling the user to identify the strengths as well as the weakesses in each of the pre-defined systems
Act Phase : ResultsQMS in Biochemistry section at WC PVL is good.Inadequate samples have detrimental effect on result quality.Haemolysis influences trace mineral levels of samples.Invalidates normal reference values.A linear relationship between haemolysis levels and all trace
mineral levels researched.A linear positive relationship exist between time before
centrifugation takes place and haemolysis level.Extent of the relationship is different from trace elements to
trace element.Haemolytic impact found to be progressive over time in all
cases.
Conclusion : Recommendations
Samples for trace element analysis must be screened for suitability for analysis.
A colour chart to be used as a practical measure in order to screen samples received for trace mineral analysis at WCPVL.
If uncertainty prevails over acceptability of a particular sample, a spectrophotometric test may be done to establish that the sample does not exceed the maximum acceptance level of 0.377nm.
Colour Chart
Henry, Cannon, and Winkelman, assert that spectrophotomic methods can be used to read hemoglobin levels. (Henry et al., 1974:6)
Modified Process MapReception: Samples arrive at Lab
Sample information captured
Samples delivered to Biochemistry Section
Sample Reception at BiochemistrySamples information recorded.Biochem lab number assigned.
Test Allocation.Samples stored under ideal
conditions until testing
Veterinarian reviewsCompiles with results from other labs
Issues report
Technologist reviews result
Issues it for release from Biochem
Validation: Checks performed to see if SOP
Followed. Controls and Standards in spec
Sample Analysis:Verifiable analytic method
according to SOP.Controlled conditions
Use of Controls and Standards
Quality Management SystemAll systems in Biochemistry
Critical Suppliers
Record keeping
Satisfied Service Customer
Quality Management Documents and Records
Additional Step:Screening Test
NO: Corrective action involves
redo
YES