1

Facilitators
Guide
2
Table of Contents
Overview 3
Objectves 4
Before Beginning 6
Module Content 7
Wrapping Up 11
Wind Down 11
Appendix 12
Assessment Tools 15
Assessment Answer Key 22
3
MLA: Peripheral Blood Smear Preparation
OVERVIEW
The goal of this learning module is to re-develop and fine tune the smear making skills
of the Medical Laboratory Assistants within the Core Laboratory. The identified goal falls
into the Psychomotor domain of learning. This goal will require the learner to utilize both
mental and physical efforts to master the task. As this module will be used to expand the
utilization of MLA skills, the learners will be proficient with several entry level safe-
ty measures before beginning the module.
The instruction itself will con- sist of several steps
and judgments that the MLA will need to master in order
for this project to be success- ful. During original training at col-
lege level, the MLA would have been taught how to produce
a blood smear. However, in many cases this training may
have occurred over a dozen years ago or provided instruction
to produce a bullet-shaped smear; within our institution
wedge-shaped smears are deemed acceptable. In addition to
variation in smear shape, teaching institutions frequently
provide students with blood drop applicators; devices that are
inserted into the flexible por- tion of the vaccutainer tube to dis-
pense consist drop size at each attempt. These devices are
costly and, consequently, frequently not used in the hospital setting. As a result, most
MLAs willingly accept basic instruction on blood smear preparation and introduction to
institution-specific smear quality criteria.
Safety Precautions:
Use of appropriate per-
sonal protective equip-
ment (lab coats, glove,
face shield)
Appropriate patient identi-
fication
Safe disposal of sharps
4

OBJECTIVES
Identification/Selection of Tools and Materials
Based on recogniton, the learner will select bevel edged glass slides that are clean and free of debris for
the purpose of preparing peripheral blood smears.
Having selected two slides, the learner will place one slide horizontally, so that the frosted end lies near-
est the dominant hand and points toward the non-dominant hand, and the other slide on vertcally, so
that the frosted end is nearest the learner and points away from the learner.
Having been asked to produce a peripheral blood smear for microscopic examinaton on Cellavision, the
learner will select clean, unused bevel edged glass slides from the slide box. The learner will lay the smear
slide horizontally and the spreader slide vertcally.
Based on personal preference, the learner will select one or two applicator stck(s), free of debris, for use
as blood applicaton tools.
Given a box of applicator stcks, the learner will select a stck(s) for the delivery of blood on to the smear
slide.
Application of Blood Drop
Given a whole blood specimen, the learner will mix the same by inversion for a minimum of two minutes.
Using the appropriate PPE, the learner will remove the cap from the tube of blood and set aside using
aseptc technique.
Given the selected applicator stck(s), the learner will insert the stck(s) into the tube of blood so that the
end is completely submerged.
Using the submerged applicator stck, the learner will withdraw the stcks from the tube of blood, dab to
remove excess blood and touch the blood coated tps to the smear slide 5 mm below the frosted edge.
Given an uncapped tube of blood, the learner will return the applicator stcks to the tube and rest it in a
test tube rack to relieve the non-dominant hand.
Given a tube of whole blood and applicator stcks, the learner will apply a drop of blood 2-3 mm in diam-
eter to the smear slide, approximately 5 mm below the frosted end.
Creating the Smear
Given a bevel edged glass slide, secure the smear slide with fnger tps so that it does not shif once pres-
sure from the spreader is exerted and so that fnger tps do not impede the movement of the spreader.
Given a clean glass slide, the learner will frmly grasp the spreader slide with his/her dominant hand.
While holding the spreader slide in the dominant hand and anchoring the smear slide with the non-
dominant hand, press the spreader slide against the smear slide just below the drop of blood so a 45
angle is created between the two slides.
With the spreader slide pressed frmly against the smear slide, the learner will pull the spreader slide
backwards, incorporatng the entre drop of blood.
Having pulled the spreader slide backward into the blood drop, the learner will pause long enough for the
blood to spread evenly across the entre length of the spreaders edge.
Having allowed the blood to spread evenly along the spreader, the learner will push the spreader with
smooth and consistent pressure along the length of the smear slide.
Having incorporated the entre blood drop, the learner will smear the blood along the length of the
smear slide so that it begins 3mm from the frosted end and terminates 10mm from the opposite edge.

5
Assessing the Quality
Given a blood smear, the learner will be able to state whether tails are present and correctly explain why this
faw makes the smear unacceptable.
Given a blood smear, the learner will be able to state whether the thin end is fat or curved and correctly ex-
plain why this faw makes the smear unacceptable.
Given a blood smear, the learner will be able to state whether there is pooling of blood at any point and cor-
rectly explain why this faw makes the smear unacceptable.
Given a blood smear, the learner will be able to state whether there are acceptable gaps on either side of the
smear and correctly explain why this faw makes the smear unacceptable.
Given a blood smear, the learner will be able to state whether the length is acceptable, correctly explain why
length is important and accurately describe steps that can be taken to correct the length.
Given a set of example blood smears and a list of criteria for an acceptable smear, the learner will be able to
identfy acceptable smears and provide justfcaton for the selecton 100% of the tme.
Discarding of Smears
Given a smear of unacceptable quality, the learner will correctly discard the slide according to sharps discard
policy and withdraw two new, clean slides.
Afer completng an acceptable smear, the learner will correctly discard the used applicator stck(s) according
to sharps discard policy.
Labeling and Staining of Smears
Having completed a successful smear and discarding used applicator stcks, the learner will promptly replace
the cap of the tube of blood.
Having completed a successful blood smear, the learner will correctly copy the frst name, last name, and speci-
men number from the tube of blood on to the frosted porton of the slide.
Given a prepared blood smear and the corresponding tube of blood, the learner will label the slide according to
patent identfcaton protocols, and promptly place the fnished smear on the slide warmer so that it will dry
without artfact.
Given dry, labelled slides, the learner will load them on to the stainer rack so that the frosted side sits at the
top of the rack.
Given a stainer rack loaded with unstained slides, the learner will slide the rack on to the stainer arm untl
locked in place.
Given the loaded stainer rack and the programming instructons provided on the top of the instrument, start
the staining program for a peripheral blood smear.
Given a blood smear of acceptable quality that has been dried and labelled, the learner will be able to demon-
strate the proper loading and programming of the stainer to stain peripheral blood smears.
6
Instruction Preparation
BEFORE BEGINNING
It is important that you prepare the learning materials and ensure that the work space can accommodate your intrusion.
Therefore, before beginning your instructon module:
In the interest of ensuring all MLAs have an opportunity to complete the training module, it would be best if a spread-
sheet is created to keep track of which individuals have completed the module, as well as to tentatvely schedule oth-
er MLAs based on availability and adequate stafng.
On the day of instructon: Check schedules to ensure that there is adequate stafng; that the laboratory will stll be
able to functon while yourself and at least one other employee are completng this module. Discuss this with man-
ager/supervisor/senior technologist if there is any doubt or uncertainty. If stafng levels are acceptable, proceed with
module
If numbers are not adequate, re-schedule the MLA for a later date.
Consult with the technologist on the hematology benchensure that there are no scheduled preventatve mainte-
nance appointments, and that both analyzers are fully functonalinform the technologist that you will be occupying
some of their work space to provide MLAs with an introducton to their smear making module and to beter familiar-
ize them with complete smear making process.
If there are any scheduled preventatve maintenance appointments or if either analyzer is not functoning to at
full capacity, delay your instructon untl things are all clear
Browse through completed sample records and select a normal, relatvely full sample (one for each of the learners to
be involved that day).
Set up a small work area for the MLA(s) to practce in lab recepton so they are out of the way of daily routnes. Ensure
all materials are available for when the learner (s) are ready to practce (test tube rack, box of slides, box of applicator
stcks, sharps discard container, paper towel/absorbent padding, PPE)
Browse through completed sample records and select samples with cold agglutnins, samples with low volume, or a
leukocyte count exceeding 300 x10
9
/Lthese samples can be used to provide enrichment to learners who easily mas-
ter the skills
7
Strategy and Delivery
MODULE CONTENT
Application of Blood Creating the Smear
Assessing the
Quality
Identification/
Selection of Tools &
Materials
Discarding the
Smears
Labeling and
Staining the Smears
1
2
Pre Instructional Activities
[Gather learner (s) in hematology area]
Welcome to your blood smear learning module! It is with great hope and investment that this project returns. I hope you are as
pleased as I am. Before we begin, I would like you to take a moment to consider the depth and breadth this new skill will ofer you.
Your involvement in patent care will be extended to play a more direct role in patent treatment. Consider your new role in terms
of this case study:
A 20-year-old female presents in the ED with shortness of breath and in a pain crisis. Her physician is partcularly interested in her
leukocyte count, platelet count, and hemoglobin. She is a known leukemic and sickle cell patent. Upon analysis of her CBC, her
leukocyte and platelet counts are fagged by the analyzer, indicatng that the results may not be valid and indicatng that a blood
smear must be made. As these crucial results must be withheld, it is imperatve that a good quality blood smear be prepared as
quickly as possible so a technologist can provide the physician with these results by means of manual counts.
In such a case, you will become an indispensable part of the Core Laboratory team!
Administer entry skill pre-testfor this just ask learner to respond verballymake notes for self regarding the performance of the
learner
Introduction
[Guide learners to stand in front of the LH750]
To begin your learning module, I would like to start by familiarizing you with the analyzer responsible for producing automated
CBC results and the process by which the CBC follows afer it leaves laboratory recepton.
[Indicate the analyzer]
This is the LH750. For every CBC sample that is loaded onto this analyzer, it provides counts of the red blood cells, white blood
cells, and platelets and measurements of the hemoglobin and white blood cell diferental (the WBC diferental includes neutro-
phils, lymphocytes, monocytes, eosinophils, and basophils) along with a few other components. The values the analyzer arrives at
are then transmited to our Laboratory Informaton System (Meditech). From here, the technologist reviews and compares the
results to a list of criteria which indicates whether a smear is required.

*The following can be directly as a script, or as a guide, depending on facilitator comfort level
8
Creating the Smear and Assessing the Quality
[Share with learners acceptable smear diagramAppendix A]
Once the technologist determines that a smear is required, it is important that the smear meet specifc criteria to ensure high
quality results are provided to the physician and front line care staf.
[Indicate smear diagram]
As you can see there are several criteria to meet in order to produce a smear of acceptable quality. You may have been originally
taught to make thumbprint smears (smears that are rounded on the thin side). This is fne, however, within our insttuton, wedge
smears are expected (smears that are fat or even across the thin side). It is even more important that these criteria be met as the
microscopic images of our slides are captured by Cellavision and then reviewed by a technologist. If the smear fails to meet some
of the criteria, Cellavision may not locate the appropriate area on the smear for which to review. This can result in delays, as
smears may need to be remade.
[Share pictures of smears with high and low hemoglobinAppendix B]
Sometmes, the components of the CBC itself make it difcult to produce a good quality blood smear. If we look at these two ex-
amples, we can see that the frst smear is very short, maybe only a centmeter in length, and is a very dark red. It is likely that this
patent has a high hemoglobin. This means that the rato of RBC to plasma will be lower than expected.
The second smear is very long, so long that it runs right of the end of the slide, and is very faintly red. It is likely that this patent
has a low hemoglobin. This means that the rato of RBC to plasma will be higher than expected.
[Share video demonstraton of smear making with high and low hemoglobin and no troubleshootngAppendix C]
In this video, the technologist is atemptng to make the blood smear using the default technique. However, because these pa-
tents fall into extreme categories, this technique falls short.
In order to make an acceptable smear for a patent with a high hemoglobin, it is necessary to increase the drop size and decrease
the angle of approach. This will allow the thick sample to spread farther along the surface of the slide.
For a patent with a low hemoglobin, it is necessary to decrease the drop size and increase the angle of approach. This will allow
the thin sample to only travel the necessary distance.
[Share video with trouble shootng steps in placeAppendix D]
[Share the image of sample blood smears with the learnersAppendix E]
This image has 3 diferent blood smears on it. Which of these smears do you think is acceptable? For the smear (s) that are not
acceptable, can you ofer an explanaton as to what might have caused the faw?
Afer we have prepared an acceptable blood smear, it is important to stain the smear. We use the Midas Stainer to stain our
blood smears.
[Guide learners over to Midas Stainer]
Afer being loaded into the stainer rack and onto the arm [Share video of how to load smears into stainer rack and onto stainer
arm] the smears move into a bucket full of methanol. This fxes the slide so it will not be washed away. The next bucket contains
Wright Giemsa stain. This stain infltrates the RBC, WBCs, and platelets on the smear. The next bucket contains the bufer, a mix-
ture of Wright Giemsa stain, 6.8 pH bufer, and water. This bucket helps to develop and diferentate the colours in the various
components. Diferentaton is partcularly important when reviewing smears on the hematology-oncology patents at our hospi-
tal. These patents tend to have a variety of immature WBC in their peripheral blood. Diferentaton allows the technologist to
distnguish between the various classifcatons of immature cells.
9
Practical Skills
Now we can being smear making!
[Guide learner (s) to smear making area in Lab Recepton]
To begin, it is important that you are able to identfy the slides we use for making blood smears: bevel edged glass slides.
[Share image comparing bevel edged slide to fat edged slidesAppendix F]
Both slides are kept in stock because the fat edged slides are used for urinalysis microscopy. Please make sure you remember
that these slides are not appropriate for use on Cellavision.
So, the frst step to preparing a blood smear is to select two of the correct slides, ensuring they are clean and free of debris. Lay
the frst slide, your smear slide, horizontally in front of you so that the frosted tp is closet to your dominant hand. Lay the sec-
ond slide, you spreader, vertcally next to your dominant hand.
You may have had the luxury of using small plastc drop applicators when you were in school to prepare smears. Unfortunately,
these devices are expensive. We will be using wooden applicator stcks to delivery the drop of blood.
[Indicate to applicator stcks]
In tme, you will come to fnd you are more comfortable using one or two stcks. This will not impact the quality of the smear but
will merely be a personal preference.
The next series of steps will be demonstrated via video clip so you can easily observe the smear making process. We will watch
the process several tme before beginning to atempt our own smears. Now that we have our slides and applicator stcks, we can
begin!
[Begin video clip, narrate throughout the sequenceAppendix G]
Ensure the specimen has been adequately mixed allow the specimen to be placed on the mixer for at least 2 minutes
before removing it.
Remove the cap of the vaccutainer tube using aseptc technique.
Using the applicator stck(s) from the previous step, insert them into the specimen, coat them in blood, then withdraw,
touch the side of the tube to remove excess blood.
Touch the blood coated tp(s) of the applicator stck(s) just below the frosted edge of the smear slide to create a blood
drop approximately 2mm in diameter
Rest the uncapped specimen, with applicator stck(s) inserted in the tube, in a test tube rack to free your hands
Anchor the smear slide with the fngertps of your non-dominant hand so that it does not shif once pressure is applied
with the spreader this will prevent movement of the smear slide as the spreader moves along its surface.
Hold the spreader slide in your dominant hand with the frosted end closest to your palm the frosted edge should not
make contact with the blood
Press the spreader slide against the smear slide just below (the side nearer the non-dominant hand) the blood drop so a
45 angle is created between the two slides this angle provides acceptable smear length given the patent has an aver-
age or just below average hemoglobin.
Pull the spreader slide backwards towards the frosted end into the drop of blood incorporatng the entre drop
Allow the drop to spread evenly along the length of the spreaders edge even spread allows for the wedge-shape
Push the spreader forward, away from the frosted end with even and consistent force even and consistent moton cre-
ates clean smears.
10
Learner Participation
Now that we have seen the demonstraton, lets all begin to familiarize ourselves with the feel and positoning materials.
[Provide students with complete patent samples]
I would like you to apply blood drops with both one and two applicator stcks so you can decide for yourself which you prefer.
Once you have a drop of blood on a slide, atempt to make a smear. I would like you to experiment with diferent angles of ap-
proach so that you can see for yourself the impact this has on the smear.
[As learners practce, observe their techniques. Ask them how they feel with the skill. Ask if they have questons or would like to
seen the demonstraton again. Provide encouragement and recogniton for good work. Gauge the actvity level of the learners,
allow them with 5-10 minutes to manipulate the materials.]
Now that you are more comfortable with the tools and materials, I would like you to produce 5 acceptable smears.
[Leave the demonstraton video available to be replayed through out the learners work so they can refer to it while they are
working on their atempts. Observe their atempts and ofer guidance. Instruct leaners to set aside smears for evaluaton. Once
all leaners have set aside at least two smears, begin to review the smears with thempromptng them for various criteria when
necessary. This process may take a while, allow them 10 minutes and request to move on. Further practce can be contnued
later]
Now that we have some smears to use and some that we will not use, we can go through the next steps. For the smears that
you will not be using, they must be discarded in a sharps disposal container to prevent injury. Please discard your unaccepta-
ble smears now.
Select one of your acceptable smears. We can now label the smear. To do this, we will discard the applicator stck(s) into the
same sharps disposal, replace the cap on our sample tube, lay it down above the frosted tp of the slide so you can copy the
date, specimen number, and full name of the patent.
Once you have done this, the smear can be placed on the slide warmer to dry. This will prevent the development of artfact.
[Guide learners over to Midas Stainer]
Once the smears are dry, we can stain them. To do this: hold the stainer rack with the thick plastc porton at the top. Slide the
smear into the rack with the frosted tp at the top. Then, take our loaded rack and slide it on the stainer arm untl it locks in
place. Remove the lids from the pots of stain, bufer, and methanol. On the number pad, press run, 6, enter to commence the
staining program. Once the staining program fnishes your smears will be ready for microscopic review!
[Once instructon has been completed, allow learners the opportunity to contnue to practce untl they feel comfortable. For
learners that require extra guidance or further challenge, refer to the Wrapping Up: Remediaton and Enrichment secton.
Administer the summatve assessment once the learner feels comfortable with the skill.]
11
Remediation and Enrichment
WRAPPING UP
Remediation
If the learner is struggling to produce the smears, you can provide reinstructon working through the core applica-
ton and smear making steps (the steps in the instructonal analysis) individually so that each is mastered independently.
This will help to identfy the area that is causing the most difculty for the learner and to break the task into smaller, more
manageable steps. The instructor can also show the learner diferent ways to anchor the slide, diferent styles of holding the
spreader, try using one applicator stck instead of two, etc.

Enrichment
If the learner has mastered the skills with very litle efort the instructor can present him/her with even more compli-
cated samples: samples that must be kept at 37 while atemptng to make the smear, samples with less than 1 mL of vol-
ume, and samples with extremely elevated leukocyte counts. These samples provide a challenge to the most confdent em-
ployees and will require a great deal more concentraton and efort for the learner to master. Provide the learner with the
samples you selected prior to beginning instructon.
Post Instruction Activities
WIND DOWN
Once instructon and summatve assessment are completed, document which MLA took part in the instructon and their suc-
cess. Archive patent samples that were selected for practce and enrichment. Clean up practce area; discard paper towel/
absorbent padding, dispose of sharps container, add slides and stcks to hematology bench stock.
12
Handouts
APPENDIX
Appendix A














Appendix B







13
Appendix E

Appendix C
Smear Making without Troubleshootng

Appendix D
Smear Making with Troubleshootng
14
Appendix G
Video of the Smear Making Process
Appendix F

15
Summative Assessment Tools
ASSESSMENT TOOLS
Entry Skill Pretest
Given the following pictures of a technologist in the process of creatng a peripheral blood smear, state whether the technologist
is using the correct personal protectve equipment for this task. If not, identfy which pieces are not being used.
Given that blood smears are produced with glass slides, state how unacceptable smears should be discarded.

How many pieces of identfcaton are necessary to label a patent's blood smear? Provide examples of what informaton may be
16

Skill mastery requires Yes outcome for all behaviours in the task check list, correct identfcaton of acceptable smears for #2, and
correct identfcaton of faws in #3.
Skills Checklist
This test item will be administered as a practcal demonstraton of the learners skills. The learner will be asked to demonstrate,
from memory, the preparaton of a blood smear. The learner is required to produce one acceptable smear before the conclusion
of the demonstraton period. The learner will be alloted 15 minutes in which to complete this task.
Each Yes results in 1 point. Each No results in 0 points. Total of 35 points for this assessment.
Summative Assessment Tools
17
18
19
20
Short Answer Questions
The following secton will address the learners understanding of concepts required for decision making involved in this pro-
cess through short answer questons. Given the test paper and pen, the learner will be asked to complete the questons. The
learner will be given 30 minutes to complete this assessment.
2. For each of the smears depicted above: (10 points 2 for each example smear)
A. State whether the smear is of acceptable quality.
B. Justfy your answer.
21
3. (3 points)
A. Why is this smear unacceptable? Suggest possible CBC parameters which would cause this. Explain what steps you
may alter in your smear making process to correct for this faw.
(3 points)
B. Why is this smear unacceptable? Suggest possible CBC parameters which would cause this. Explain what steps you
may alter in your smear making process to correct for this faw.
22

ASSESSMENT ANSWER KEY
Entry Skills Pretest
In the frst image, the technologist is using all the appropriate personal protectve equipment: gloves, lab coat, and face shield.

In the second image, the technologist is not using the face shield, but is using gloves and a lab coat.

In the third image, the technologist is only using the lab coat and not the gloves and face shield.

Glass slides and applicator stcks must be disposed of in puncture resistant containers to prevent other staf members from
accidental "stck" injuries.

Two pieces of patent informaton are required to safely label a blood smear. The patent's full name and specimen number can
be used.



Summative Assessment
#2.
A. Unacceptable too short, smear runs of side of slide
B. Acceptable straight, even across botom, good length, no tails or pooling
C. Unacceptable too short, rounded botom
D. Acceptable straight, even across the botom, good length, no tails or pooling
E. Unacceptable signifcant pooling

#3 A. This smear is too short and the thin end is not even across the botom. This patent likely has a high hemoglobin. In
order to produce an acceptable smear it will be necessary to decrease the angle of approach/increase drop size
#3 B. This smear is too long. This patent likely has a low hemoglobin. In order to make an acceptable smear it will be nec-
essary to increase the angle of approach/decrease drop size.