Vet Clin Small Anim 37 (2007) 237–244

VETERINARY CLINICS
SMALL ANIMAL PRACTICE
Quality Control Recommendations and
Procedures for In-Clinic Laboratories
M. Glade Weiser, DVMa,b,*, Mary Anna Thrall, DVM, MSa,c
a
Department of Microbiology, Immunology, and Pathology, College of Veterinary Medicine
and Biomedical Sciences, Colorado State University, Fort Collins, CO 80523, USA
b
Heska Corporation, 3760 Rocky Mountain Avenue, Loveland, CO 80538, USA
c
Department of Pathobiology, Ross University School of Veterinary Medicine,
Basseterre, St. Kitts, West Indies

Q
uality control monitoring of hematology and clinical chemistry instru-
mentation diagnostics has been established in clinical and commercial
laboratories from their inception. Everyone acknowledges in principle
that quality control monitoring also applies to in-clinic laboratory instrumenta-
tion. This acknowledgment has been poorly reduced to practice in the veteri-
nary facility, however. The universally recognized necessity for in-clinic
quality control in laboratory diagnostics was re-emphasized to the veterinary
profession several years ago [1]. The cited publication suggested that quality
control procedures used in professional laboratories might be too extensive
for the small veterinary facility, but an alternative solution was not provided.
More recently, the Committee for Quality Assurance and Standards of the
American Society for Veterinary Clinical Pathology (ASVCP) formulated
a comprehensive document for quality control standards applicable to all vet-
erinary laboratories. These are published on the organization’s web site [2].
The society is commended for taking a leadership position for formulating
these standards in the absence of regulatory oversight of veterinary laboratory
testing. In-clinic laboratory endeavors are veterinary laboratories and, as such,
should move toward implementation of quality control monitoring.
Lack of regulation in veterinary testing is one factor in quality control mon-
itoring not being well reduced to practice in veterinary hospital facilities. As
a result, most users are left to follow recommendations of suppliers of diagnos-
tic instrumentation. Some suppliers state or imply that their respective systems
do not require quality control monitoring. Although this may seem expedient
and appealing to the user, it is misleading and contrary to ASVCP guidelines.

Dr. Weiser is a shareholder and part-time employee of Heska Corporation. Dr. Thrall is a part-time
employee of Antech Diagnostics.

*Corresponding author. Heska Corporation, 3760 Rocky Mountain Avenue, Loveland, CO

80538. E-mail address: weiserg@heska.com (M.G. Weiser).

0195-5616/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.cvsm.2006.11.006 vetsmall.theclinics.com
238 WEISER & THRALL

Because of the proliferation of in-clinic laboratory endeavors, it is recommen-

ded that the profession, users, and suppliers catch up on implementation of do-
able quality control monitoring in veterinary facilities. The overall goal here is
to demystify implementation of quality control monitoring and encourage in-
creased adoption for laboratory testing in the veterinary hospital.
With that background, the purposes of this article are as follows:
1. To describe the design and use of quality control monitoring material
2. To review the rationale and advantages for quality control monitoring of in-
clinic instrumentation
3. To propose a simplified program of quality control monitoring for adoption
by the small veterinary laboratory and front-line veterinary medicine
4. To describe hematologic procedures using patient samples that are an ad-
junct to the quality control program
5. To mention the role of interlaboratory proficiency testing programs
6. To provide an example of an exception

QUALITY CONTROL MONITORING MATERIAL DESIGN

AND USE
Control samples are designed to be similar to and analyzed like patient sam-
ples. They must also have a reasonable shelf life and open vial stability. To
achieve that combination of features, the materials may be treated in ways
that are part of the art of creating these products. For clinical chemistry, the
material starts with pooled serum in which analytes may be spiked to achieve
desired concentrations. For hematology, the erythrocytes are from pooled
whole blood. The platelets and leukocytes are not stable and are not present
in the material. Other particles are added to mimic leukocytes and platelets
in hematology controls.
Once these materials are prepared to create a ‘‘lot,’’ they are assayed by ref-
erence procedures to establish known concentrations or measurements that are
indexed to standards. The materials are then assayed on carefully maintained
instruments of the type supported in the field. These data are used to define lot-
specific target assay ranges for the instrument type being supported. The limits
of assay value ranges are defined by statistical treatment of data from a rela-
tively large number of repetitive analyses on the instrument system. These
limits are designed to accommodate the variation that is expected to exist in
a family of the same instrument type. These limits should be similar to the Clin-
ical Laboratory Improvement Amendments (CLIA) guidelines for acceptable
variability presented in the article by Weiser and colleagues found elsewhere
in this issue. The user’s individual analyzer range performance from day to
day is likely tighter than the assay ranges.
For the user, it is critical that control materials have assay values specific for
the analyzer type and method being used. For example, one cannot use a mate-
rial having assay values for analyzer type X and use it for analyzer type Y. It is
possible for a laboratory to obtain a control material and develop its own assay
QUALITY CONTROL FOR IN-CLINIC LABORATORIES 239

values, but these procedures are not recommended for the typical in-clinic lab-
oratory. As a result, the best source of control material and program is from the
supplier supporting the user’s instrument.
The logistics of the in-house control program in the facility are as follows.
Analysis of control material is performed on a regular basis once per day at
the startup of daily patient sample testing. Each day, the results of analysis
are checked by inspection against the target assay value ranges. The goal is
documentation that the system is recovering the values within the assay value
range. Because the assay value ranges can usually be entered into the system
software, the user interface may be used to simplify this inspection with a sys-
tem of results flagging. The system or attached computer system should also
accumulate the daily quality control data so that the data are available for trend
inspection or submission to technical support if needed. Finally, the control ma-
terial may be spot-analyzed at any time that the system is questioned or if pa-
tient results are questioned.
The user may encounter quality control values that fall outside the assay
limits. Following are some action guidelines for this occurrence, but, ultimately,
action should be directed by the specific user manual and supplier technical
support.
 It is anticipated that an occasional measurement may fall barely outside the
assay limits. For most programs, there is approximately a 1% probability of
this occurring. This does not require action if it is an isolated incident and
the value returns to the assay limit range on the next control sample analysis.
Some laboratories immediately repeat a control sample when a value is barely
out of range.
 If a measurement or set of measurements is clearly falling outside the assay
limits by an appreciable magnitude, action should be taken to determine
the cause. Action should be based on specific instructions for a system as de-
fined in its user manual and additional information provided by the supplier.
 It may be noticed that a certain measurement or set of measurements consis-
tently runs near the lower or upper assay limit. This is an indication that the
system may be in need of calibration to move the measurements toward the
control program mean value. Any action should be based on specific instruc-
tions for a system as defined in its user manual and additional information pro-
vided by the supplier.

RATIONALE AND ADVANTAGES OF QUALITY CONTROL

MONITORING IN HEMATOLOGY AND CLINICAL CHEMISTRY
Technical Perspective
From the technical perspective, laboratory instrumentation performs a complex
series of activities, such as automated pipetting, dilutions, mixing, measure-
ments involving current or light, and data reduction. Components like tubing,
valves, printed circuit boards, and moving parts are subject to deterioration and
eventual failure. Any developing defect or failure in such a complex electrome-
chanical system has an impact on the integrity of final laboratory test results
240 WEISER & THRALL

that the system generates. Quality control monitoring was invented to detect
this impact on laboratory test results before putting the data into use by the cli-
nician. This has been the objective of daily quality control monitoring pro-
grams being implemented as standard operating procedure in clinical
laboratories. Daily quality control monitoring programs should be imple-
mented as standard operating procedure in clinical laboratories, regardless of
size. Regular use of a control sample ensures that the system is performing
to specification in its ability to recover values of the sample with known values
anchored to reference procedures.

Clinician’s Perspective
From the clinical perspective, a quality control program enables the clinician to
interpret laboratory data with greater confidence. Clinicians are frequently pre-
sented with laboratory test results that are surprising or not in keeping with
preconceived expectations for a given case. This inherently raises questions
about the accuracy of those results. A daily quality control monitoring program
provides a day-to-day confidence level that patient results have a high probabil-
ity of being reliable. In addition, the daily quality control program provides the
following benefits:
 The daily program is pre-emptive of inefficient and frustrating after-the-fact sys-
tem troubleshooting with controls only after patient results are questioned. This
is particularly difficult if there are no control materials on hand.
 Examination of historical quality control data, generally the last 20 to 30
days, along with a current control sample is an essential first step in instrument
troubleshooting when a problem does occur. This is highly valuable for inter-
acting with the supplier’s technical support.
 The cumulative quality control data are a source of information for evaluating
the system’s reproducibility performance over time.
 Most think that the value of quality control is to detect the occasional occurrence
of a system problem. It is proposed that the peace of mind associated with
documenting the absence of a problem on a daily basis is of greater value.

PROPOSED APPROACH TO SMALL LABORATORY QUALITY

CONTROL MONITORING
To date, there has not been uniform treatment of the question of what consti-
tutes a reasonable quality control program for the in-clinic veterinary laboratory.
Models of quality control programs exist in human medical laboratories. These
are a result of regulation. Most large veterinary laboratories have adopted these
guidelines without rethinking them. Standard laboratory guidelines call for anal-
ysis of control materials each laboratory shift. Control programs also typically
consist of three levels for hematology, known as low, normal, and high, and
two levels for clinical chemistry, known as normal and abnormal. Laboratories
may insert additional control samples throughout the day when running large
numbers of samples. This may result in 5 to 10 or considerably more quality
control analyses for hematology and clinical chemistry per day. These
QUALITY CONTROL FOR IN-CLINIC LABORATORIES 241

guidelines are daunting for the in-clinic veterinary laboratory. This not only con-
sumes considerable time and consumables, but the evaluation of that much data
is disproportionately difficult for the objective being considered.
The following is the rationale for a recommended streamlined approach to
make quality control monitoring more efficient and palatable for the in-clinic
laboratory endeavor. The genesis of multiple levels of control was related to
an era when method and instrument linearity was variable and less than ideal.
Over the years, there has been marked improvement in measurement dynamic
range and linearity. As a result, it is proposed that a multiple-level control pro-
gram is an obsolete concept for small clinical laboratories. It is also a vestige of
large laboratory programs as a result of regulation that is slow to reinvent his-
torical procedures.
It is therefore recommended that single-level controls are adequate for in-
house veterinary laboratories. For hematology, this should be the normal level
or midrange control. For clinical chemistry, this should be the high or abnor-
mal level control because some analytes, such as bilirubin, are near zero in
the normal-level material. The frequency of quality control analysis is recom-
mended to be once each working day for reasons discussed previously. This
is also adequate for the in-house veterinary laboratory.
In summary, a program of one control sample per working day for each he-
matology and chemistry analyzer is efficient, economic, and quite doable for
the in-clinic laboratory. It is recommended that the profession and suppliers
work together to achieve this kind of program tailored to the needs of in-clinic
veterinary laboratories.

HEMATOLOGIC PROCEDURES THAT ARE A SUPPLEMENT

TO THE QUALITY CONTROL PROGRAM
There are a couple of tools that may be applied to patient samples to verify an-
alyzer performance on individual samples. One tool is the blood film, as de-
scribed in the article by Weiser and colleagues found elsewhere in this issue.
The other important and underutilized tool is the mean cell hemoglobin con-
centration (MCHC) value.
Blood Film Review
As mentioned in the article by Weiser and colleagues found elsewhere in this
issue, the blood film is an essential quality adjunct to verification of selected
platelet and leukocyte measurements. This requires use of a good-quality mi-
croscope and well-prepared blood films. Detailed descriptions of blood film ex-
amination are delegated to textbooks of veterinary clinical pathology. Some
examples of verifications include the following:
 If the analyzer produces an extremely low or extremely high cell concentra-
tion, it is easy to verify that result by scanning the blood film with low magni-
fication. For an extremely low cell concentration, leukocytes are rare to absent
on the blood film. Conversely, for an extremely high concentration, the leuko-
cyte density is increased compared with normal.
242 WEISER & THRALL

 For patients with abnormal leukocyte concentrations or distributions within the

differential, it is important to verify these by a microscopy differential. In these
situations, analytic systems may misclassify cells. Also, analytic systems do not
identify or classify bands, toxic change, mast cells, or abnormal cells in leuke-
mic states. As a result, many veterinary laboratories routinely perform micros-
copy differentials and do not report instrument differentials.
 When platelet concentration is decreased on an analyzer measurement, it is
important to verify this by scanning the blood film for platelet microclots that
may result in a false low measurement.
Mean Cell Hemoglobin Concentration Value
The MCHC value has minimal clinical usefulness but is a highly useful system
quality control tool in real-time analysis of patient samples. The rationale is as
follows. The MCHC is calculated from the hematocrit (HCT) and hemoglobin
concentration values. Within common domestic animal species, the MCHC
value is a physiologic constant (typically ranging from 32–38 g/dL) that may
be used to monitor the relation between the hemoglobin concentration and
HCT. The HCT and hemoglobin concentration are measured in completely
separate blood dilutions and analytic subsystems. If there is a system malfunc-
tion in either of the dilutions or subsystem measurements, it may be reflected in
the MCHC value. Because these are independent measurements, the hemoglo-
bin value corroborates the HCT value, and vice versa, for each sample. There
are also a few pathologic sample conditions that result in MCHC abnormali-
ties. On instrument systems that measure HCT and hemoglobin concentration
directly, MCHC abnormalities may be considered in the following way.
Low mean cell hemoglobin concentration
There is no pathologic condition that results in a severe decrease in the
MCHC. Extreme erythrocyte regeneration (eg, >25% reticulocytes) may be as-
sociated with MCHC values in the range from 29 g/dL to normal. Historically,
a decreased MCHC has been associated with iron deficiency anemia. With
modern analytic instruments, however, erythrocyte sizing measurements and
blood film morphology are much more sensitive for detecting erythrocyte
changes associated with iron deficiency. An MCHC between 29 and 32 g/dL
should not be interpreted as indicative of iron deficiency without corroborating
changes in erythrocyte volume abnormalities, blood film changes, and serum
iron biochemistry. MCHC values less than 28 g/dL suggest the high probabil-
ity of a system problem that should be evaluated with blood controls and sup-
plier-recommended troubleshooting. The same is true for MCHC values in the
range of 28 to 32 g/dL if this is reasonably consistent across multiple patient
samples.
High mean cell hemoglobin concentration
An MCHC value that exceeds 38 g/dL should prompt review of a checklist of
pathologic conditions that may cause this. This list includes the following:
 Increased turbidity in the hemoglobin measurement by spectrophotometry.
Known causes are lipemia (most common), a high concentration of large
QUALITY CONTROL FOR IN-CLINIC LABORATORIES 243

Heinz bodies in cats, and extreme leukocytosis (typically >150,000 per

microliter).
 Marked sample hemolysis such that preanalytic lysis of erythrocyte results in
a false low HCT.
 Erythrocyte agglutination that does not disperse in the dilution in which the
HCT is measured. The HCT is falsely decreased because agglutinated erythro-
cytes are not included in the measurement. The hemoglobin measurement is
accurate. This occurs frequently in immune-mediated hemolytic anemia.

Once the causes on this checklist are ruled out and there is an unexplainable
high MCHC, attention should turn to evaluation of the instrument system with
controls. In particular, if high MCHCs are occurring across multiple samples,
the instrument system should be evaluated for proper function. MCHC values
that bounce around sporadically for no apparent reason are an indication of
poor system reproducibility. This is also important because leukocytes are mea-
sured in the same dilution as hemoglobin.

COMMENTS ON INTERLABORATORY QUALITY CONTROL

PROGRAMS
Relatively early in the evolution of professional human and veterinary clinical
laboratories, interlaboratory control programs were established to assess how
individual laboratories compared with a large number of other laboratories
in analysis of an aliquot of the same sample. One historical advantage of this
program is that it provided considerable perspective on how much variation
could be expected between laboratories for common laboratory tests. Diagnos-
tics companies and laboratory organizations administered these programs.
Laboratories participate in the program three to four times per year, usually
quarterly. The administering entity distributes aliquots of a single sample to
each subscribing laboratory. Laboratories then analyze the sample and return
results for analysis. The laboratory subsequently receives a statistical report in-
dicating how its result compares with a mean value and dispersion based on
results from all laboratories.
Some years ago, the Veterinary Laboratory Association (VLA) initiated such
a program for veterinary laboratories. Most commercial laboratories, veterinary
teaching hospitals, and some research laboratories participate in this program.
Few veterinary hospitals participate in an interlaboratory quality control
program. At this point in time, this is not likely to change. This is attributable
mostly to the lack of education and awareness about in-clinic quality control
programs in general. In addition, it is not recommended without widespread
adoption for the following reasons. First, it would take most or a large critical
mass of veterinary hospital facilities to subscribe simultaneously to achieve in-
terpretable comparison. This is because in-clinic laboratories are using differ-
ent instrumentation and methods compared with large laboratories enrolled in
the program. Second, an interlaboratory program is not a substitute for an
internal program of regular quality control monitoring. Once per quarter is
too low a frequency for there to be value in determining if a system problem
244 WEISER & THRALL

exists. Therefore, interlaboratory programs are only a supplement to a daily

internal quality control program. This may change in the future if a supplier
offers its user group a similar program in which the users may compare their
results with other users in the same instrument family. As implied in this sec-
tion, the profession is encouraged to attain a simple interlaboratory compar-
ison program that is tailored to its needs.

AN EXCEPTION
There is at least one blood testing system that is a unique exception to these
principles and recommendations (i-STAT analyzer; Heska Corporation, Love-
land, Colorado). The design of the system is such that it is not compatible with
the use of conventional quality control monitoring programs because the sys-
tem is, in effect, a new instrument each time a sample is analyzed. The instru-
ment does not pipette sample, makes no dilutions, and has no tubing to age. It
uses disposable cartridges that contain microfabricated housing of reference so-
lution, sample chambers, ion selective membranes, and electrodes for electro-
chemical measurements. The instrument reads electrical signals from the
cartridge. For each cycle, it performs a series of electronic checks on cartridge
performance, electrical contact, and sample loading. Any defect in cartridge or
electronic performance is detected and messaged along with blockage of results
reporting. One can run a control sample on a cartridge, but when the next sam-
ple is analyzed, it is on a new instrument because all the conventional sample
analysis components are housed in the next cartridge. Cartridge performance is
quality controlled at the point of manufacturing. The user may run controls to
facilitate learning how to use the system and verify recovery of expected re-
sults, but this does not control user ability to handle whole-blood samples
from patients properly. A batch or lot of cartridges may also be evaluated
with controls if shipping or storage conditions have been violated or are other-
wise in question. There are likely to be other diagnostic devices in the future
with a design that is not amenable to conventional quality control monitoring.

SUMMARY
The design and use of quality control materials and rationale for implementa-
tion of a quality monitoring program have been discussed. A simplified ap-
proach to a quality monitoring program suitable for in-clinic laboratories has
been presented. Use of blood films and the MCHC value as adjuncts to quality
monitoring in hematology has been described. Over time, it is hoped that the
profession more widely embraces, if not demands, implementation of quality
monitoring for in-clinic laboratory diagnostics.
References
[1] Freeman KP, Evans EW, Lester S. Quality control for in-hospital veterinary laboratory testing.
J Am Vet Med Assoc 1999;215:928–9.
[2] American Society for Veterinary Clinical Pathology. Quality assurance guidelines. Available
at: www.asvcp.org/publications/qas-guidelinemenu.html. Accessed December 26, 2006.