International Journal of Laboratory Hematology

The Official journal of the International Society for Laboratory Hematology

ORIGINAL ARTICLE INTERNATIONAL JOURNAL OF LA BO RATO RY HEMATOLOGY

Optimization of laboratory workflow in clinical hematology

laboratory with reduced manual slide review: comparison
between Sysmex XE-2100 and ABX Pentra DX120
M. HUR*, J.-H. CHO*, H. KIM*, M.-H. HONG*, H.-W. MOON*, Y.-M. YUN*, J. Q. KIM †

*Department of Laboratory SUMMARY

Medicine, Konkuk University
School of Medicine, Seoul, Korea
†
Konkuk University, Seoul, Korea
Correspondence:
Mina Hur, Department of
Laboratory Medicine, Konkuk
University School of Medicine,
Konkuk University Hospital, 4-12,
Hwayang-dong, Kwangjin-gu,
Seoul 143-729, Korea.
Tel.: +82 2 2030 5581;
Fax: +82 2636 6764;
E-mail: dearmina@hanmail.net
This work was supported by
Konkuk University in 2010.
doi:10.1111/j.1751-553X.2011.01306.x
Received 24 September 2010;
accepted for publication 21
December 2010
Keywords
Slide, review, Sysmex XE-2100,
ABX Pentra DX120, hematology
Introduction: The validation of automated hematology analyzer results
by manual slide review (MSR) is currently an inevitable work process
in clinical hematology laboratories. The laboratory workload would
be optimized if the requirement for MSR could be reduced without
compromising patient care. We investigated whether slide-making
rates would be different between two hematology analyzers, which
were paired with their own automated slide makers/stainers: Sysmex
XE-2100 with SP-1000i (Sysmex, Kobe, Japan) and ABX Pentra
DX120 with SPS evolution (ABX-Horiba, Montpellier, France).
Methods: A total of 943 samples were run in parallel on the Sysmex
XE-2100 and ABX Pentra DX120. Reflex slides were automatically
made in each analyzer according to its own criteria, which reflected
the criteria of MSR in our laboratory. The slide-making rates were
compared, and the results were further confirmed using the criteria
of MSR.
Results: The slide-making rates in Sysmex XE-2100, ABX Pentra
DX120, and manual review were 22.5% (212/943), 15.91% (150/
943), and 11.5% (108/943), respectively. In 774 (82.1%) samples,
the three methods showed concordant results, and all made slides in
82 samples. Using the manual method as a standard, the sensitivity
and specificity were 86.1% and 85.8% in Sysmex XE-2100 and
89.8% and 93.7% in ABX Pentra DX120.
Conclusion: Our data show that the slide-making rates are variable in
different hematology analyzers. It also implies that although MSR
cannot be fully substituted by modern hematology analyzers, it can
be effectively reduced to optimize laboratory workload.

requested tests in clinical laboratories. Technical evo-

INTRODUCTION
lutions in automated hematology analyzers have
The complete blood count (CBC) with leukocyte dif- improved the analytic performance greatly and have
ferential counts (LDC) is one of the most frequently broadened the range of information provided (Buttarello

434  2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 434–440
 M. HUR ET AL.
& Plebani, 2008). Among the traditional CBC parame-
ters, the red blood cell count (RBC), hemoglobin con-
centration (Hb), white blood cell count (WBC), and
mean cell volume generally show excellent analytical
function, while the results for reticulocytes, platelet
counts, or certain components of LDC are less satisfac-
tory (Buttarello, 2004; Segal et al., 2005). The clinical
applications and analytical function of the newly
introduced parameters, such as reticulocyte indices,
immature reticulocyte fraction, reticulated platelets, or
immature granulocytes, have not yet been fully estab-
lished or standardized (Buttarello et al., 2002; Sand-
haus & Meyer, 2002; Briggs et al., 2004; Thomas et al.,
2005).
Despite the high-quality performances and
expanded capabilities of automated analyzers, the
manual examination of blood smears still plays an
important role in hematology laboratories. Each labo-
ratory has its own decision-making criteria or rules
for the validation of quantitative abnormalities or
qualitative alterations that are highlighted (flagged)
and which trigger slide preparations and reviews as
reflex tests (Lantis et al., 2003; Barnes et al., 2005).
The laboratory workload and efficiency of generating
the final CBC report are widely affected by the num-
ber of manual slide review (MSR) performed and are
variable between laboratories (Novis et al., 2006). Lab-
oratory work processes would be optimized if the
number of MSR could be reduced without compro-
mising patient care.
Automated slide makers and strainers, together
with their hematology analyzers, are widely used in
high-volume hematology laboratories (Simson, Gas-
con-Lema & Brown, 2009). In such situations, reflex
slides are automatically prepared after the generation
of abnormal CBC data, with no manual intervention
by experienced laboratory staff. Although each labora-
tory has criteria that trigger reflex slides, the imple-
mentation of these criteria in the different
hematology analyzers could vary according to the
characteristics of each analyzer. Consequently, the
rates of slide preparation and review might be highly
affected. This study investigated whether the slide-
making rates were different between two hematology
analyzers that were paired with their own automated
slide makers/stainers: Sysmex XE-2100 with SP-1000i
(Sysmex, Kobe, Japan) and ABX Pentra DX120 with
SPS evolution (ABX-Horiba, Montpellier, France).
 2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 434–440
REDUCED SLIDE REVIEW IN HEMATOLOGY LABORATORY 435
MATERIALS AND METHODS
A total of 943 patient samples were randomly selected
from the daily routine workload of our hematology
laboratory and were run in parallel on the Sysmex
XE-2100 and ABX Pentra DX120. Reflex slides were
automatically prepared by each analyzer according to
its own criteria, which were programmed to reflect
the criteria of MSR in our laboratory. To increase the
clinical sensitivity, the criteria in each analyzer were
developed not to miss any pathological samples. The
slide-making rates were compared between the two
analyzers, and the results were further confirmed with
those of manual review. One expert senior technolo-
gist checked all the CBC data and reflex slides that
were automatically prepared from each analyzer and
slide maker/stainer combination to choose the slides
to be reviewed. Using the manual review as a stan-
dard, the sensitivity and specificity of each analyzer
were obtained.
The decision-making criteria for MSR in our labo-
ratory are presented in Figure 1. The Sysmex XE-2100
is used as the main hematology analyzer in our labo-
ratory, and the workflow of slide review was devel-
oped according to the use of this analyzer and its
automated slide makers/stainer, the SP-1000i
(Figure 2). One of the criteria for slide review was to
review all the samples from the hematology depart-
ment regardless of CBC abnormalities. Accordingly, in
addition to the main workflow of slide preparation
through SP-1000i, we needed another process to iden-
tify samples from the hematology department, for
which slides were not prepared. For such samples,
slide preparation and staining were performed manu-
ally. The rules for slide making in the Sysmex XE-
2100 are listed in Table 1, and the workflow of the
rules in ABX Pentra DX120 is summarized in Figure 3.
The main differences in the rules between the Sysmex
XE-2100 and ABX Pentra DX120 were that depart-
ment information and delta check could be included
in the criteria for the ABX Pentra DX120.
To compare the diagnostic performances of Sysmex
XE-2100 and ABX Pentra DX120, their sensitivities
and specificities were analyzed using MedCalc Soft-
ware (version 11.2.1; MedCalc Software, Mariakerke,
Belgium). The statistical differences in their sensitivi-
ties and specificities were obtained with chi-square
test.
436 M. HUR ET AL. REDUCED SLIDE REVIEW IN HEMATOLOGY LABORATORY

Figure 1. The decision-making criteria for manual slide review.

Figure 2. Workflow of slide review with Sysmex XE-2100 and SP-1000i.

22.5% (212/943), 15.91% (150/943), and 11.5%

RESULTS
The comparison data of slide preparation by Sysmex
XE-2100, ABX Pentra DX120, and manual review
are presented in Table 2. The slide-making rates in
Sysmex XE-2100, ABX Pentra DX120, and MSR were
(108/943), respectively. All the three methods showed
concordant results in 774 (82.1%) samples: all posi-
tive in 82 samples and all negative in 692 samples.
Discrepant results were observed in 169 samples. No
case showed a positive result by manual review but

 2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 434–440
 M. HUR ET AL.
Table 1. The rules for slide making in Sysmex XE-2100
Quantitative abnormalities
Leukocytopenia/leukocytosis: WBC < 2.0 · 109/l or
WBC > 20 · 109/l
Neutropenia/neutrophilia: neutrophils < 30% or
neutrophils > 85.5%
Lymphocytopenia/lymphocytosis: <10% or >70%
Monocytosis: monocytes > 15.5%
Eosinophilia: eosinophils > 20%
Basophilia: basophils > 2%
Nucleated RBCs > 2/100 WBCs
Thrombocytopenia/thrombocytosis: PLT < 100 · 109/l or
PLT > 600 · 109/l
Flags
PLT clumps or abnormal distribution
Fragments
Blasts
Immature granulocytes
Left shift
Atypical lymphocytes
Abnormal lymphocytes/lymphoblasts
WBC, white blood cell count; RBC, red blood cell count;
PLT, platelet count.
negative results by both Sysmex XE-2100 and ABX
Pentra DX120. However, there were discrepant results
between the Sysmex XE-2100 and ABX Pentra DX120
in 26 samples with positive MSR results: 15 were Sys-
mex negative and Pentra positive and the other 11
were Sysmex positive and Pentra negative. Using
MSR as a reference method, the sensitivity and speci-
ficity were 86.1% (95% confidence interval (CI),
78.1–92.0%) and 85.8% (95% CI, 83.2–88.0%) in
Sysmex XE-2100 and 89.8% (95% CI, 82.5–94.8%)
and 93.7% (95% CI, 91.8–95.2%) in ABX Pentra
DX120, respectively (Table 3). Significant differences
in the specificity and specificity of the analyzers were
observed, with a difference of 3.7% (95% CI, 0.69–
6.71; P = 0.0165) for sensitivity and 8.0% (95% CI,
5.2–10.8; P < 0.0001) for specificity (chi-square test).
The causes of false-positive and false-negative
results were analyzed (Table 4). In the 119 samples
with false-positive results by Sysmex XE-2100, slide
flag was the most frequent cause followed by delta
check and department; slide flag and/or delta check
comprised three-quarters (75.7%) of the total false-
positive causes. In ABX Pentra DX120, the two causes
of false-positive results were slide flag (64.2%) and
monocytosis with large immature cells (35.8%).
 2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 434–440
REDUCED SLIDE REVIEW IN HEMATOLOGY LABORATORY 437
Regarding false-negative results, the causes were
department (n = 11) and absence of result (n = 4) in
Sysmex XE-2100, and absence of flag (n = 11) in ABX
Pentra DX120. The quantitative values or flags in 11
samples with false-negative results by ABX Pentra
DX120 are presented in Table 5. The Sysmex XE-2100
also showed flags and/or quantitative abnormalities
that triggered MSR in these 11 samples. However,
these did not correspond to our criteria for the
manual confirmation, except for one sample with 3%
basophils (sample 8).
DISCUSSION
The manual examination of blood smears is time-con-
suming and expensive and may not be always neces-
sary. To increase the clinical sensitivity, most
laboratories tend to develop less strict criteria so as
not to miss potentially important abnormalities. This
would be more conspicuous especially when a hospi-
tal has a large pool of hemato-oncological patients.
According to the College of American Pathologists’
Q-Probes Study with 263 participating institutions,
the rates of MSR varied considerably among partici-
pants (26.7% in the median, 9.9% in the 10th per-
centile, and 50.0% in the 90th percentile institutions)
and were elevated with increased numbers of hospital
beds (Novis et al., 2006). That study showed that the
rates of MSR were directly related to the efficiency in
generating CBC results. Most of the MSR were trig-
gered by hematology analyzer flags, and these thresh-
old limits also varied widely among participants.
Recently, the use of automated slide makers and
stainers has increased in large-sized clinical laborato-
ries. They are used in combination with their multipa-
rameter hematology analyzers, and their performances
are reported to be comparable to well-prepared man-
ual processes (Simson, Gascon-Lema & Brown, 2009).
Compared with manual procedures, the introduction
of automated slide makers and stainers has signifi-
cantly reduced the workload of slide preparation as
well as the turn-around-time of the final CBC report.
On the other hand, not all the automatically prepared
slides are reviewed manually. If slide-making rules of
the instrument do not perfectly match the slide-review
criteria of the laboratory, there may be a discrepancy
between the prepared slides and reviewed slides. Con-
sidering the general policy of laboratories not to miss
438 M. HUR ET AL. REDUCED SLIDE REVIEW IN HEMATOLOGY LABORATORY

Figure 3. Workflow of the rules for slide making in Pentra DX120. PDX, ABX Pentra DX120; SPS, SPS evolution;
PML, Pentra multilink data management system.

Table 2. Slide preparation by Sysmex XE-2100, ABX Table 3. Comparison of the results between Sysmex
Pentra DX120, and manual review XE-2100, ABX Pentra DX120, and manual review

Sysmex ABX Pentra Manual Number Sysmex XE-2100 ABX Pentra DX120
XE-2100 DX120 review (%)
Positive Negative Positive Negative
Positive Positive Positive 82 (8.7)
Positive Negative Positive 11 (1.2) Manual review
Negative Positive Positive 15 (1.6) Positive 93 15 97 11
Negative Negative Positive 0 (0) (n = 108)
Negative Negative Negative 692 (73.4) Negative 119 716 53 782
Positive Negative Negative 90 (9.5) (n = 835)
Negative Positive Negative 24 (2.5)
Positive Positive Negative 29 (3.1)

Positive means the slide preparation, and negative vice
versa.
any possible pathologic samples, the presence of these
unnecessarily prepared slides might be regarded as
inevitable. However, construction of the rules to
reflect the laboratories’ own criteria may be variable in
each hematology analyzer, and consequently, the gap
between the prepared and reviewed slides may be dif-
ferent. To the best of our knowledge, no study has
focused on this practical issue in routine hematology
laboratory so far.
This study investigated whether the slide-making
rates would be different between two hematology
analyzers when paired with their own automated slide

 2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 434–440
 M. HUR ET AL. REDUCED SLIDE REVIEW IN HEMATOLOGY LABORATORY 439

Table 4. Causes of false-positive and false-negative results by Sysmex XE-2100 and ABX Pentra DX120

Sysmex XE-2100 ABX Pentra DX120

False-positive Total (n = 119, 100%) Total (n = 53, 100%)

Slide flag (n = 46, 38.7%) Slide flag (n = 34, 64.2%)
Delta check (n = 34, 28.6%) Mono + Lic (n = 19, 35.8%)
Department (n = 21, 17.6%)
Slide flag and delta check (n = 10, 8.4%)
Department and delta check (n = 8, 6.7%)
False-negative Total (n = 15, 100%) Total (n = 11, 100%)
Department (n = 11, 73.3%) No flag (n = 11, 100%)
No result (n = 4, 26.7%)

Mono + Lic, monocytosis and large immature cells.

Table 5. Quantitative values or flags in samples with false-negative results by ABX Pentra DX120

Quantitative values (%) or flags

Dep ABX Pentra DX120 Sysmex XE-2100 Manual differential count (%)

1 IM Lic: 1.0 Abn L/L-Blasts N: 67, Nb: 2, L: 25, M: 6

2 IM E: 16.9 Eosinophilia, Blasts N: 65, L: 8, M: 8, E: 19
3 IM No flags Abn L/L-Blasts N:73, L:16, M:6, E:3, B:2
4 IM Lic: 1.0 Aty L N: 73, Nb: 2, L: 17, M: 4, E: 1, B: 2, Aty L: 1
5 IM Lic: 2.2 Immature Granulocytes N: 78, Nb: 2, L: 12, M: 4, E: 2, B: 1, Mm: 1
6 IM M:13.6, Lic: 0.4, Aty L: 1.5 Abn L/L-Blasts N: 43, Nb: 1, L: 39, M: 13, E: 3, B: 1
7 IM nRBC, platelet aggregates, Basophilia N: 65, Nb: 1, L: 22, M: 7, E: 4, B: 1
monocytosis, (M: 11.4,
Lic: 0.6, Aty L: 1.4)
8 IM Lic: 0.8, Aty L: 0.9 Blasts N: 46, Nb: 2, L: 43, M: 6, B: 3
9 PED Neutropenia (M: 10.2, Neutropenia, N: 15, Nb: 4, L: 64, M: 11, E: 3, B: 2, Aty L: 1
Lic: 0.8, Aty L: 2.2) Abn L/L-Blasts
10 IM Lic: 2.0, Aty L: 1.7 Aty L N: 79, Nb: 4, L: 10, M: 5, B: 1, Aty L: 1
11 IM M: 12.8, Lic: 0.9, Aty L: 1.4 Aty L N: 61, L: 25, M: 9, E: 2, Aty L: 3

Dep, department; IM, internal medicine; PED, pediatrics; Lic, large immature cells; Aty L, atypical lymphocytes; Abn L,
abnormal lymphocytes; nRBC, nucleated RBCs; L-Blasts, lymphoblasts; N, neutrophils; Nb, band-form neutrophils; L,
lymphocytes; M, monocytes; E, eosinophils; B, basophils; Mm, metamyelocytes; My, myelocytes.

makers/stainers: Sysmex XE-2100 with SP-1000i and
ABX Pentra DX120 with SPS evolution. Our data
showed that the sensitivity and specificity of slide
preparation were different between these two systems
and that the performance of ABX Pentra DX120
with SPS evolution was superior to that of Sysmex
XE-2100 with SP-1000i (Table 3). In particular, the
number of false-positive samples was decreased in
ABX Pentra DX120, and the main causes of difference
were attributable to ‘delta check’ and ‘department’,
which could not be included in the rules for Sysmex
XE-2100 (Table 4). ‘Department’ was also the main
cause of false-negative results in Sysmex XE-2100,
and in the routine practice of our laboratory, this was
one of the main causes of extra workload.
Eleven samples showed false-negative results by
ABX Pentra DX120 with no flags. In contrast, they
mostly showed flags of blasts, atypical lymphocytes, or
immature granulocytes and/or quantitative abnormali-
ties by Sysmex XE-2100 (Table 5). According to our
decision-making criteria for slide review, MSR was
triggered by the results of Sysmex XE-2100, and the

 2011 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 434–440
440 M. HUR ET AL. REDUCED SLIDE REVIEW IN HEMATOLOGY LABORATORY

results by ABX Pentra DX120 were considered false-
negative. The manual counts on these 11 samples,
however, showed that the review process was not nec-
essary for most of the samples, except for one sample
with 3% basophils. Accordingly, the actual false-nega-
tive rate of ABX Pentra DX120 would be lower and
the specificity would be higher than the obtained data.
Our study has several limitations. It was conducted
to compare the slide-making rates between the two
analyzers, but the rules of ABX Pentra DX120 were
constructed in accordance with our decision-making
criteria, in which the pre-existent Sysmex XE-2100
played a main part. Accordingly, MSR, a reference
method, might have itself affected the comparison
data possibly toward increased false-negative results
by ABX Pentra DX120. Another limitation is that the
manual review rate in this study (108/943, 11.45%)
was relatively lower than the usual review rate in our
laboratory. The average manual review rate was
26.9% in our laboratory for the period August 2009–
July 2010, ranging from 20.0% to 39.0%. It can be
explained by the fact that, for this study, we avoided
the busiest day of the week and the busiest time of
the day, although we tried to conduct it as a routine
practice. This bias might have decreased the difference
in slide-making rates and affected the causes of dis-
crepant results.
Manual slide review to validate the results from
automated hematology analyzers is currently an inevi-
table work process in clinical hematology laboratories,
and the efficiency of generating CBC results may be
affected by how to set both instrument threshold trig-
gers and laboratory policies (Novis et al., 2006). Despite
suggested criteria, the criteria for MSR seem to be still
variable across laboratories (Barnes et al., 2005). The
use of automated slide makers and stainers has
decreased manual workload and increased laboratory
efficiency. Considering that automated slide prepara-
tion triggers MSR, if the slide-making rates are variable
among different hematology analyzers, it would
directly affect the slide-review rate in the laboratory.
Such an impact would be greater in high-volume labo-
ratories, especially if there is a large pool of hemato-
oncological patients. In summary, our data showed
that, even with the same laboratory criteria for slide
review, the slide-making rules could not be con-
structed equally in different analyzers and the slide-
making rates therefore varied. This study implies that
in addition to the automation of slide preparation,
there is a room for further optimization of laboratory
workload and efficiency by adjusting the slide-making
rate to each laboratory’s situation. More comprehen-
sive effort is required to streamline the workflow and
improve the productivity in hematology laboratories.

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