Transcript Flags and Codes on the Beckman Coulter GenS System

Flags, Codes and Messages
on the COULTER® LH 750/755
Rev. F (October 2009)
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What’s the difference between
a Flag, a Code and a Message?
• Flags
 Letters or Symbols that appear to the
right of a result
• Codes
 Symbols that appear in place of results
• Messages
 Word messages provide additional
information
Suspect
Definitive
Decision (Reflex) Rules
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COULTER® LH 750
FLAGS
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The * Flag
• Result does not meet the counting
•
threshold for MCV (i.e. less than 50 fL)
There could be interference causing the
reported result to be falsely low
 Red background on the Workstation screen
 Suspect message (RBC Interference)
 R on all RBC parameters, all Plt parameters
and Retic #
 Do not report RBC results
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The * Flag
What could you do?
Review RBC Histogram
Review the morphology from the smear
Do a spun hematocrit
Perform a manual RBC count
Review according to your lab’s policy
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The + Flag
• Result exceeds linearity (reportable)
•
range
The LH 700 Series reportable ranges:
WBC - 0.00 to 400.0 x 103 cells/µL
RBC - 0.00 to 8.00 x 106 cells/µL
Hgb - 0.0 to 25.0 g/dL
Plt - 0.00 to 3000 x 103 cells/µl
• The
+ appears on results between the
linear and operating range
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The + Flag
What could you do if a parameter result
has a single plus?
 Perform a dilution of a sample aliquot.
 Run the sample in the predilute mode
using the dilution factor made.
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Operating and Reportable Ranges
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The H/L, aH/aL, cH/cL Flags
• These are flags that appear based on
•
your laboratory’s reference, action and
critical limits
Can set up multiple sets of these
ranges based on age and location
(optional) in the Workstation
 Each set then has subsets for Male (Def.),
Female, Action, Critical and Definitive
Messages
• Review according to your lab’s policy
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The H/L, aH/aL, cH/cL Flags
The ranges for these flags are set up under
System Setup…Patient…Flagging Limits
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The D Flag
• Indicates the result triggered a Delta
Check as defined by your laboratory
• Review according to your lab’s policy
• Set up under System Setup…Patient…
Decision Rules
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The D Flag
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The E/e Flags
• The E shows a result that has been
manually edited
 An E will also appear if the Sample ID
(tube barcode) is edited
• The e shows a result that has been
recalculated from a manually edited
parameter
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The E/e Flags
• Results are edited by selecting the “Edit
this sample” button located on the
specific toolbar
 Demographics and/or comments may also
be added on this screen
• To save the edit, select the “save” icon
on the specific toolbar
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The E/e Flags
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The P Flag
• The instrument detected a partial
aspiration error (break in the flow of
blood during sample aspiration)
OR
• The blood detectors are disabled
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The P Flag
Why do you think this sample gave a P flag?
 Hemoglobin is less than 4 g/dL
What should you do?
 Check sample to verify no clots and rerun in
the Manual aspiration mode
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The P Flag
This example does not have an obvious reason
for the P flag.
What should you do?
Check sample for proper blood volume in the tube
Check for clots
Ensure blood detectors are enabled
Rerun in Automatic mode
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The P Flag
What to Do for persistent P flags
 Troubleshoot for leaks, kinks or plugs along
the sample flow path
 Ensure the aspiration lines are clean
 Check for needle plugs
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The R Flag
• Review results before reporting
according to your lab’s protocol
• This flag is generated in response to
suspect messages
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The R Flag
Cellular Interference
R appears next to WBC when the
separation between the WBC
populations is poorly defined
RBC Interference
MCV*, all RBC, Plt, and Retic #
parameters will have R
Low Event #
(<800 WBC events)
R appears next to all diff % & #,
NRBC % & # display incomplete
computation (....) when this message
appears
Platelet Clumps
R appears next to Plt parameters
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The R Flag
Verify Diff or WBC >1.5 and
MO% >20
R appears next to differential
and NRBC percentages and
absolute numbers
Verify Retic
R appears next to Retic %,
Retic #, IRF, and MRV
WBC Exceeds Linearity
Uncorrected WBC > 400. A
plus sign (+) appears next to
the WBC and an R appears
next next to the RBC, Hgb, Hct,
MCV, MCH, MCHC, RDW and
the diff % & #
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The R Flag
This example shows an R flagged Plt
Note the
abnormal Plt
histogram
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COULTER® LH 750
CODES
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The (- - - - -) Code
• Total voteout of the parameter
 Can appear for CBC parameters
 Means that two of the three aperture
values do not agree
 No average histogram appears for the
affected parameter
• You may review the individual
aperture results on the CBC Data tab
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The (- - - - -) Code
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The (- - - - -) Code
What to Do
 Rerun the sample
 Ensure baths contain diluent
 Ensure apertures are not blocked.
Clear Aperture key
F01 (Clear Apertures)
F09 (Zap Apertures)
 Use F03 to ensure Mixing Bubbles are
present. A lack of mixing bubbles can
cause increased voteouts.
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The (+++++) Code
The result exceeds the instrument’s
operating range.
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The (+++++) Code
What should you do if a parameter
result has an over range code ?
Perform a dilution of a sample
aliquot.
Run the sample in the predilute
mode using the dilution factor
made.
If your result is a single + or another
+++++ rerun using regular manual
mode and do the math yourself.
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Carryover
You need to be aware of carryover issues
related to + and +++++. Blood-to-diluent
Carryover on the LH 750 should meet
these limits:
WBC
RBC
Hgb
Plt
DIFF
RETIC
<2.0%
<1.0%
<2.0%
<2.0%
<200 events
<600 events
When a sample has a high count, even this
amount of Carryover may be too high.
Always verify the results of the sample that
come after a high one by repeating it.
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The (…..) Code
• An incomplete computation of a CBC
•
parameter
Can occur on calculated parameters
due to the primary parameter used in
the calculation having either:
a voteout (-----) or
exceeding operating range (+++++)
• For example, if the WBC has the
voteout (-----) code, the diff absolute
#s will appear as (…..)
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The (…..) Code
What to Do
Rerun the sample if the primary
parameter has a voteout (-----)
Make the necessary dilution if the
primary parameter exceeds the
operating range (+++++)
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The (:::::) Code
• May appear for Diff or Retic
• The instrument suspects a clog in
the flow cell
• One of the following designations
will appear on the dataplot.
PC1 or PC2 or FC
• Note: this code may be misleading
as there is not always a flow cell
clog…… more on this in the
Troubleshooting Basics 1 (TB1)
module
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The (:::::) Code
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The (:::::) Code
What To Do
• if One sample
Repeat, if still no results, perform
manual diff
• if Many samples
Run Latron to troubleshoot
F44, F45
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®
COULTER LH
Suspect Messages
Definitive Messages
and
Decision Rules
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750
Suspect Messages
• Appear for sample results based on
abnormal cell distribution or
population
• System generates the message
according to an internal algorithm
using information from data plots or
histograms
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Suspect Messages
• The LH 750 has the option of
adjusting the sensitivity of certain
differential suspect messages
• Should confirm abnormalities by
microscopic review
• Review sample results per your
lab’s protocol (e.g. confirm
abnormalities by review)
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Suspect Messages (“research”)
13 suspect messages are considered
“research” only
 Viewed only if the research button is
selected
 Not required as part of your review
protocol
 Can not be transmitted
 Print only when the research button is
selected
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Suspect Messages
Sample result with 2 suspect messages
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Definitive Messages
• Appear based on action limits
entered in System Setup, Patient,
Flagging Limits
• Review according to your lab’s
protocol
• Includes “H&H Check Failed”
 Is preset, cannot be adjusted
 Can be turned off/on at the Run
Configuration Screen
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Decision (Reflex) Rules
• Messages that appear with results
based on rules entered by your lab
• Rules that can be thought of as “ifthen” statements, e.g.
 If the WBC is ≥ 20.0, then “Perform a
manual diff”
 The “then” part of the statement appears in
the comments area on the sample results
printout and on the Demographics tab in
Rule Messages box
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Decision (Reflex) Rules
You may create an unlimited number of
rules
 A maximum of 20 rules can apply to one
sample result
 The priority of the rules can be changed
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Summary
BCI suggests using all available flagging
options to optimize the sensitivity of
instrument results based on your patient
population. All flagging options include:
 Reference Ranges (H/L), Action (aH/aL) &
Critical (cH/cL) limits
 Definitive messages
 Suspect messages
 Parameter codes
 Decision rules/Delta checks
 System alarms
Avoid using single messages or outputs
to summarize results.
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COULTER® LH 750
Corrected and
Uncorrected WBC
Counts
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WBC Correction
The following slides will
present some examples of the
WBC correction feature on the
LH 700 Series
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Causes of Cellular Interference
Unlysed RBCs
Platelet Clumps
Giant Platelets
NRBCs
Malarial parasites
Fragmented WBCs
Cryoglobulins
Agglutinated WBCs
Precipitated elevated proteins
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WBC Correction
WBC histogram showing significant
interference to the WBC count
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WBC Correction
WBC histogram showing poorly defined
cell populations
There will be an R and a red
background if the separation between
the populations is poorly defined.
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WBC Correction
If the algorithm determines that the particles
are not significant, then no correction is
made. No suspect message posted. No need
to review.
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WBC Correction– Example 1
•
•
•
•
•
Results: WBC = 2.8, NRBC% = 0.0
Avg. WBC and uncorrected count are equal
Smear Review: 1 NRBC/100 WBC
Review WBC Histogram:
Should you correct the WBC?
 No, since the population was <35 fL, it never interfered

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with the WBC. Could review smear.
Enumerated NRBC is only reported from 2% or greater.
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WBC Correction– Example 2
• Results: WBC = 7.6
• Avg.WBC = 7.6 uncorrected count = 8.3
• Suspect Msg: Cellular Interference, NRBC
• Review WBC Histogram:
NRBC
• Smear Review: 5 NRBC/100 WBC
• Enumerated NRBC – Disabled
• Should you correct the WBC?
 No, it’s already corrected. WBC correction operates
independently of the NRBC parameter. Review smear.
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WBC Correction– Example 3
•
•
•
•
Results: WBC = 8.6, NRBC% = 9.8
Avg.WBC = 8.6 uncorrected count = 9.5
Suspect Msg: Cellular Interf. ,Plt Clumps
Review WBC Histogram:
•
•
•
Enumerated NRBC – Enabled
Smear Review: 11 NRBC/100 WBC
Should you correct the WBC?
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 No, it’s already corrected. Review smear.
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WBC Correction– Example 4
•
•
•
Results: WBC = 25.1, NRBC = 6.9%
Avg.WBC and uncorrected count are the
same
Review WBC Histogram:
•
•
•
Enumerated NRBC – Enabled
Smear Review: 7 NRBC/100 WBC
Should you correct the WBC?
 NRBCs were not included in the count as they are
<35 fL. Review smear.
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WBC Correction– Example 5
•
•
•
•
Results: WBC = 8.5R, NRBC% = 5.0
Avg. WBC = 8.5R and uncorrected WBC = 9.3 R
Suspect Msg: Ly Blasts, Cellular Interf.
Review WBC Histogram:
•
•
•
Enumerated NRBC – Enabled
Smear Review: 44 NRBCs/100 WBC
Should you correct the WBC?
 Yes, most of these NRBCs are >35 fL in size and fall in the
Lymph area.
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WBC Correction– Example 6
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•
•
•
Results: WBC = 9.7, NRBC% = 2.9
Suspect Msg: Platelet Clumps
Review WBC Histogram:
•
•
•
Enumerated NRBC – Enabled
Smear Review: 3 NRBC/100 WBC, Clumped
Platelets
Should you correct the WBC?
 No correction is necessary. Review smear.
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THE END
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