UK NEQAS
UK NEQAS
Who are we, what do we do and, Who
are we what do we do and
by the way
by the way, where does all that blood go?
BARBARA DE LA SALLE
BARBARA DE LA SALLE
Manager General Haematology UK NEQAS Scheme Manager
General Haematology UK NEQAS Scheme
Chair UK NEQAS Executive
MEGAN ROWLEY
Director Blood Transfusion Laboratory Practice and Director
Blood Transfusion Laboratory Practice and
Fetomaternal Haemorrhage UK NEQAS Schemes
Consultant Haematologist NHSBT (Colindale) and Imperial (St
Consultant Haematologist NHSBT (Colindale) and Imperial (St Mary’s)
PRIYA PATEL
PRIYA PATEL
UK NEQAS for Microbiology
Virology Laboratory Team Manager
What is the UK NEQAS organisation?
What is external quality assessment and why do we need
and why do we need it?
You provide some of the blood for our exercises
How does NHSBT help UK NEQAS?
How does UK How
does UK
Q
p
NEQAS help NHSBT?
You participate in our exercises as part of your f
QA programme
UK NEQAS
Dr Mitchell Lewis
The father of UKNEQAS
40 years of quality
1969
2009
All UK NEQAS designated schemes
All
UK NEQAS designated schemes are members of the are members of the
UK NEQAS Consortium – a not‐for‐profit company limited by guarantee and a UK Registered Charity
limited by guarantee and a UK Registered Charity The UK NEQAS organisation, served by its elected The
UK NEQAS organisation served by its elected
Executive Committee and the UK NEQAS Office, fulfils central co ordinating and administrative functions
central co‐ordinating and administrative functions
www.ukneqas.org.uk
UK NEQAS is part of the
UK NEQAS facilitates optimal patient care by providing a p
q
y
comprehensive external quality assessment service in laboratory medicine
Through education and the promotion of best practice, it
promotion of best practice, it helps ensure that the results of investigations are reliable
are reliable and and
comparable wherever they are produced
d d
UK NEQAS Code of Practice
UK NEQAS Code of Practice
Since 1969 the United Kingdom National External
Quality Assessment Service (UK NEQAS) has
been providing a comprehensive world-wide
service that enables laboratories to fulfil quality
goals and facilitate optimal patient care
A code of practice exists to ensure that schemes
work together with common values and for the
benefit of participants and the patients for whom
laboratory services are provided
UK NEQAS in Partnership
UK NEQAS in Partnership
UK NEQAS is an
Organisation
UK NEQAS now comprises a
comprises a network of 144 schemes
144 schemes operating from 24 centres based at centres based at
major hospitals, research institutions and universities th
throughout the h t th
UK
4 May, 2010
The services cover qualitative
and interpretative investigations
in andrology,
andrology cellular pathology
pathology,
clinical chemistry, genetics,
haematology, immunology and
microbiology
The UK NEQAS
Organisation
Haematology
Division
Microbiology
Division
Chemistry
Division
UK NEQAS
Consortium
Immunology
Division
Miscellaneous
Schemes
Histopathology
Division
UK NEQAS Haematology Division
UK NEQAS Haematology Division
Watford General Hospital
f d
l
i l
– General Haematology
– Blood Transfusion Laboratory Practice
– Feto‐Maternal Haemorrhage
g
• Sheffield Hallamshire Hospital
– Blood Coagulation
Blood Coagulation
– Leucocyte Immunophenotyping
• Good Hope Hospital, Birmingham
G dH
H i l Bi i h
– Haematinics
Antibody screening
ABO/D typing
Antibody identification
R d ll
Red cell phenotyping
p
yp g
Emergency testing
Emergency testing
Crossmatching
NQAAP
CPA
Inspection and
accreditation
Poor
Performance
UK NEQAS
SCHEME
Professional advice
and review
Steering
Committee
Joint
Working
Group
Who sees the
information?
Performance
monitoring and
education
Participants
Most schemes offer participation to overseas laboratories
p
p
Over 8,000 from over 100 countries regularly participate in UK NEQAS exercises
UK NEQAS (H) Participants
UK NEQAS (H) Participants
Total
UK
Novartis
POC
Total
instruments
FBC
980
571
96
2118
ADLC
744
501
96
1393
Reticulocytes
483
334
Blood
Bl
d Fil
Films &
Parasites
542
372
Cytochemistry
212
184
Abnormal Hbs
419
296
G6PD
224
160
Red Cell Mass
40
40
Vitamin B12 absorption
45
45
Scheme
At July 2008
803
Participants in BTLP
Participants in BTLP
A
Area
UK/Eire
Number of
participants
471
Scandinavia
61
Rest of Europe
85
Middle East
30
Far East
3
Africa
3
EXTERNAL QUALITY ASSESSMENT
Quality ‘Umbrella’
Total Quality
Management
Quality
Assurance
Quality
Management
System
Output
Quality Control
What is EQA?
What is EQA?
External assessment of results from a group of laboratories where each tests identical h
h t t id ti l
specimens of “known‟
specimens of known but but
undisclosed content
Internal Quality Control:
Internal Quality Control:
Are today’s results the same as yesterday’s?
External Quality Assessment:
External Quality Assessment:
Are my results the same as other laboratories?
Blood Transfusion Laboratory
Blood Transfusion Laboratory
Every Time
Every Time
Right Blood – Right Patient ‐ Right Time
In blood transfusion,, adverse events are reported
p
via the
SHOT and MHRA SABRE reporting systems
T
Transfusion
f i Incident
I id t
EQA exercise
i
Actual Error
Potential Error
SHOT
Near Miss
EQA is a free lesson for your lab
lab, and for everyone else’s
else s
“Never have hospital labs been exposed to so much scrutiny”
However balanced the professional
professional message about transfusion safety there seems to be a public public expectation of ‘zero risk’
LABORATORY BLUNDERS
“Laboratory
Laboratory
workers bungle
simple tests.
Patients die.”
die.”
“The error rate for ABO
grouping in UK NEQAS
exercises is 0.01% and
the majority
j
y of these are
clerical errors”
Quality Assessment Why Do It?
Quality Assessment‐Why Do It?
•
•
•
•




Accuracy of laboratory tests
Performance of equipment & reagents
q p
g
Integrity of testing systems
Proficiency of staff
Proficiency of staff
For our patients
For
our patients
For ourselves
F
For accrediting authorities (CPA, MHRA)
diti
th iti (CPA MHRA)
For national performance review (NQAAP)
NHSBT as EQA participants
NHSBT as EQA participants
ABO & D grouping, Antibody g p g,
y
screen and antibody ID, crossmatching
Fetomaternal haemorrhage (FC)
RCI labs
FBC
Abnormal Hb
Quality Monitoring
Donor Testing
Low level leucocyte couting
CD34 counting
Quality Monitoring
Therapeutic Apheresis
Hepatitis A, B, C
p
HIV (many more! See Priya’s list)
T
Transfusion microbiology
f i
i bi l
Any others?
Any others?
Participating laboratories are Participating laboratories are
identified by a code known only to the Scheme Organiser/Director and key UK
Scheme Organiser/Director and key UK NEQAS personnel
Specimens are distributed at a regular Specimens di t ib t d t
l
frequency, and aim to cover the range likely to be encountered in clinical
likely to be encountered in clinical practice
Participants receive independent, Participants i i d
d t
objective and impartial reports on their performance enabling them to identify
performance, enabling them to identify weakness and take appropriate action
Performance Standards
Performance Standards
Realistic
• Achievable by most laboratories Achievable by most laboratories
• Not discouraging participation
• Not unmanageable for the scheme
Safe
• Major errors with potential for serious impact on patient care are recognised as unsatisfactory
EQA display in haematology lab
Exercises have greater value if participants have the ‘right attitude’
EQA Samples should be handled, as far as possible the same as routine samples
possible, the same as routine samples
Not:
• Always same senior staff
• With additional techniques
• More than once
More than once
• In consultation with other labs
Performance
Performance is analysed by method is analysed by method
group
Errors discussed with participants
p
p
Participant report and performance
Participant report and performance score after each exercise
EDUCATION REINFORCING GUIDELINES ADVICE AND SUPPORT
Unsatisfactory Performance
U
ti f t
P f
• Requires corrective and preventative action
Persistent unsatisfactory performance yp
(PUP)
• Different definition for different schemes Diff
t d fi iti f diff
t h
but failure to improve
Now, lets mention the blood…
SUPPLY OF MATERIAL FROM NHSBT
Many UK NEQAS schemes Many
UK NEQAS schemes
are dependent on NHSBT p
(and WBS and SNBTS) for bl d d bl d
blood and blood components
NON‐CLINICAL ISSUE SYSTEM
*NHSBT
Clinical or waste product
*NHS
Leucodepleted RBCs
Leucodepleted RBCs
Whole Blood Donor
Clinical or waste product
Whole blood
Waste product
‘Normal’ plasma
Component Donor
EQA directed
‘Disease’ plasma
Disease plasma
*And some material comes from commercial suppliers
Venisection Patient
Therapeutic Apheresis Priority of NHSBT has to be to provide blood Priority
of NHSBT has to be to provide blood
for therapeutic use
‘Non‐clinical issue’ is also important • p
provides research material and reagents g
• supports quality improvement via EQA, teaching and training
• May result in acceptance of some donors who would otherwise be rejected
otherwise be rejected
• Means that ‘waste’ products or ‘unsuitable for clinical use’ are put to some use
li i l
’
tt
• The NHSBT has an income from it
Consent
• Standard donor consent covers most aspects p
g
g
p
of EQA providing the original product is a whole blood donation
• Special donors or special products have to be Special donors or special products have to be
consented separately
• Quite rightly, donors would want their blood to be used for therapeutic purposes most of
to be used for therapeutic purposes most of the time
Changes to NCI
Changes to NCI
• Reorganisation of processing, testing and y
distribution centres within NHSBT may alter existing local arrangements
• ‘Competition’
Competition for limited resources with other for limited resources with other
non‐clinical blood component users • vCJD measures stop previously transfused patients being blood donors and therefore
patients being blood donors and therefore less RBC antibodies for transfusion exercises
ORGANISATION OF EQA SCHEMES ‐
MICROBIOLOGY
Virology Schemes
Virology Schemes
• Anti‐HBs detection
• Blood Borne virus
• Diagnostic serology (exanthem screen)
• Diagnostic serology (hepatitis screen)
(hepatitis screen) • Hepatitis B serology
• Hepatitis C serology
Hepatitis C serology
• HIV serology
Immunity screen
• Immunity screen
• Rubella IgG serology
• Syphilis serology
yp
gy
Virus identification
HBV DNA quantification
Hepatitis C RNA detection
HIV1 RNA quantification
Molecular detection of HPV
Molecular detection of viruses in CSF
• CMV DNA quantification
f
•
•
•
•
•
UK NEQAS
UK NEQAS
UK NEQAS f Mi bi l
UK NEQAS for Microbiology
How is the blood used?
Purchased positive for a marker e.g. anti‐HCV, anti‐HIV, syphilis serology
Purchased negative for the above and used as diluent for other markers
Screened and characterised for common markers in the population
Used as plasma/serum dependant on the scheme type.
UK NEQAS
UK NEQAS
Markers brought from elsewhere:
• Acute disease state plasma such as Rubella Acute disease state plasma such as Rubella
IgM, Acute EBV markers, Acute ASO and Erythrovirus B19 IgM
Erythrovirus B19 IgM
• Plasma negative for VZV IgG, Rubella IgG
• Usually supplied by commercial sources
U ll
li d b
i l
NHSBT as EQA participants in UK NHSBT
as EQA participants in UK
NEQAS for Microbiology gy
•
•
•
•
•
Hepatitis B serology
Hepatitis
B serology
Hepatitis C serology
HIV serology
Immunity Screen (HAV, CMV, VZV IgG)
Syphilis serology
Dispensing of serology specimens
Dispensing of serology specimens
UK NEQAS
UK NEQAS
Exactly how much blood??
• UK NEQAS for Microbiology uses approximately 76 litres of serum per year
approximately 76 litres of serum per year
• Equates to 90 litres of blood!!
Specimen packing
Specimen packing
ORGANISATION OF EQA SCHEMES ‐
HAEMATOLOGY
Watford UK NEQAS Centre @ Watford General Hospital
General Haematology
Blood Transfusion Laboratory Practice
Fetomaternal Haemorrhage
Admin and office area: thinking and paperwork!
and paperwork! Laboratory: preparation and testing
Annexe – packaging and distribution
Do we really use all that Do
we really use all that
in a year?
in a year? (Not to mention the
(Not to mention the blood!)
A few useless facts about the
A
few useless facts about the
UK NEQAS Unit at Watford
Glass wine and nappies
Glass, wine and nappies
Enough glass vials to make
27,000 champagne glasses
We could soak up 2,000 bottles
of wine with the absorbent pads
(k
(known
as ‘nappies’
‘
’ to us)) used
d
in the survey packages
Odds and ends envelopes and queries
Odds and ends, envelopes and queries
Apart
p
from the thousands of
gloves, tissues and elastic
bands we use,, we post
p
you
y
39,000 paper envelopes and
answer the p
phone 2,500
,
times a year (and every
phone call is logged!)
p
gg )
Up to our ears in paper
Up‐to‐our‐ears‐in‐paper Please be patient if
we make the
occasional mistake.
We manually enter
well over a million
items of data a year,
and that is just for
Haematology surveys
Worldwide appeal
Worldwide appeal
We receive post from 80 countries
on all 5 continents.
We have no shortage of staff willing
to deliver items to exotic faraway
places,, but we could use someone
p
prepared to walk to the Royal Mail
post depot on a wet, cold afternoon
i January
in
J
to make
k sure the
h
package forgotten by the postman
arrives in time!
F ll bl d
Full blood count exercises
i
•
•
•
•
Fresh
Fresh EDTA blood is unsuitable EDTA blood is unsuitable
We prepare stabilised blood Taken from healthy donors
Cli i ll b
Clinically abnormal cases are l
simulated
Individually consented donors ……
Survey Package
Summary
• UK
UK NEQAS is an organisation that supports individual NEQAS is an organisation that supports individual
schemes to provide exercises covering a wide variety of laboratory tests
of laboratory tests
• It is provided for professionals, by professionals who work in partnership to improve patient care
work in partnership to improve patient care
• All the blood you provide to us really makes a difference, so diff
THANK YOU!
A few other examples
A few other examples
UK NEQAS for HbA1C (Clinical Chemistry)
UK
NEQAS for HbA1C (Clinical Chemistry)
• Used to monitor diabetics
• Diabetic donors have been recruited and are Di b ti d
h
b
it d d
consented and bled for EQA exercises UK NEQAS for Fetomaternal haemorrhage
UK
NEQAS for Fetomaternal haemorrhage
• Simulated bleed of fetal cells into mother
• Fetal cells are waste red cells from cord blood bank, F t l ll
t
d ll f
d bl d b k
maternal cells are non‐LD donor cells A few other examples
A few other examples
UK NEQAS for CD34
UK
NEQAS for CD34
• Waste apheresis tubing (from NBS) is drained to provide 100ml of CD34+ rich blood
provide 100ml of CD34+ rich blood
• Samples of fixed CD34+ rich blood are mixed with a filt d it
filtered unit
UK NEQAS for low level leucocyte counting
UK
NEQAS for low level leucocyte counting
• Small amounts of fixed buffy coats mixed with fixed filtered blood or platelets to make samples fixed filtered blood or platelets to make samples
with suitable cell counts