Establishing external quality assessment programmes for screening of donated blood for transfusion-transmissible infections: implementation guide

Implementation Guide Establishing External Quality Assessment Programmes for Screening of Donated Blood for Transfusion-Transmissible Infections Establishing External Quality Assessment Programmes for Screening of Donated Blood for Transfusion-Transmissible Infections Implementation Guide WHO Library Cataloguing-in-Publication Data Establishing external quality assessment programmes for screening of donated blood for transfusion-transmissible infections: implementation guide. 1.Blood Transfusion - adverse effects. 2.Blood Transfusion - standards. 3.Disease Transmission, Infectious - prevention and control. 4.Donor Selection. I.World Health Organization. ISBN 978 92 4 151583 2 This publication was originally published under ISBN 978 92 4 151043 1 (NLM classification: WB 356) © World Health Organization 2016 All rights reserved. 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Contents ACKNOWLEDGEMENTS ABBREVIATIONS INTRODUCTION 1 1 EXTERNAL QUALITY ASSESSMENT 3 1.1 EQA as part of a quality system in the screening of donated blood for TTI 3 1.2 Assessment 4 1.3 External quality assessment 5 1.4 Objectives and benefits of EQA 5 1.5 EQA programmes 6 2 ESTABLISHING EQA PROGRAMMES FOR TTI SCREENING 8 2.1 Organizing institution 8 2.2 Advisory committee 10 2.3 Technical and administrative support 11 2.4 Information management system 12 2.5 Finances 13 2.6 Quality system of the EQA programme 14 2.7 Participating laboratories 15 2.8 Pilot study 16 2.9 Practical steps in establishing an EQA programme 16 3 PARTICIPATING LABORATORIES 18 3.1 EQA programme information manual 18 3.2 Rules of participation 19 3.3 Registration 20 4. PRACTICAL CONSIDERATIONS IN ESTABLISHING AN EQA PROGRAMME 22 4.1 Scope 22 4.2 EQA programme exercise format 22 4.3 EQA programme objectives 23 4.4 Sources of exercise material 23 4.5 Establishing a sample bank 24 4.6 Processing candidate exercise material 25 4.7 Exercise documentation 29 4.8 Logistics 31 5. PLANNING AND OPERATING AN EQA PROGRAMME FOR TTI TESTING 32 5.1 Developing an annual EQA programme plan 32 5.2 Developing the plan for a specific EQA exercise 33 5.3 Selection of material for EQA exercises 33 5.4 Preparation of exercise materials 34 5.5 Dispensing exercise material 34 5.6 Verifying homogeneity and stability 35 5.7 Verifying stability 36 5.8 Packing and dispatch 37 5.9 Collection of and deadline for EQA results 37 5.10 Collation of EQA results 38 5.11 Analysing EQA results 38 5.12 Statistical analysis of EQA exercise results 39 5.13 Preparation of EQA reports 40 5.14 Preliminary report 40 5.15 Final report 40 5.16 Certificates of participation 41 6. MONITORING LABORATORY PERFORMANCE, FEEDBACK AND EDUCATION 42 6.1 Setting standards of acceptable performance 42 6.2 Numerical scoring systems for performance monitoring 43 6.3 Follow-up of unsatisfactory performance 43 6.4 Self-assessment 44 6.5 Education 44 7. MONITORING AND EVALUATING AN EQA PROGRAMME 46 7.1 Indicators 46 7.2 Impact 47 7.3 Annual report 47 GLOSSARY 48 ANNEXES 51 1. Preliminary questionnaire for potential participating laboratories 52 2. EQA registration form 54 3. Exercise instruction sheet 55 4. Exercise results form 56 5. Protocol for homogeneity testing of exercise material 59 6. Protocol for stability testing of exercise material 61 7. Record of exercise distributions and returned results 63 8. Exercise analysis and report 64 9. Numerical scoring systems 68 Acknowledgements The Blood Transfusion Safety Programme in the WHO Department of Service Delivery and Safety wishes to express its thanks to the experts in external quality assessment screening for transfusion-transmitted infections who contributed to the development of these guidelines. Authors Ms Susan Best and colleagues National Serology Reference Laboratory Melbourne, Australia The authors also acknowledge the following individuals who prepared the WHO publication External quality assessment of transfusion laboratory practice: guidelines on establishing an EQA scheme in blood group serology (WHO/ EHT/04.09), to which the present publication is a companion. Ms Jenny White, Deputy Scheme Manager, NEQAS for Blood Transfusion Laboratory Practice Watford, United Kingdom Mr Robin Knight, Red Cell Immunohematology Service Development Manager, National Blood Service, North London Blood Centre, United Kingdom Editorial team and contributors Dr Wilai Chalermchan, Senior Laboratory Advisor (contractor), Thailand MOPH – U.S. CDC Collaboration (TUC) Dr Marcia Mitiko Otani, Chefe Depto Controle de Qualidade Serologia, Fundação Pró-Sangue Hemocentro de São Paulo, Brazil Dr Neelam Dhingra, Coordinator, Patient Safety and Quality Improvement, Service Delivery and Safety, WHO Dr Noryati Abu Amin, Medical Officer, Blood & Transfusion Safety, Service Organization and Clinical Interventions Unit, Service Delivery and Safety Department, WHO Mr Junping Yu, Technical Officer, Blood & Transfusion Safety, Service Organization and Clinical Interventions Unit, Service Delivery and Safety Department, WHO Critical readers Dr Alan Kitchen, Head of National Transfusion Microbiology Reference Laboratory, NHS Blood and Transplant, United Kingdom Dr Jane Carter, Amref Health Africa, Wilson Airport, Langata Road, Nairobi, Kenya Dr Vengetassen (Ravi) Reddy, Chief Operations Officer, South African National Blood Service Dr Vivienne James, Northern Sydney Central Coast Health, Australia Dr Xun Wang, Head of Transfusion-Transmitted Disease Laboratory, Shanghai Blood Centre, China Dr Panadda Silva, Director/Expert at Department of Medical Sciences, Ministry of Health, Thailand The publication was coordinated by Dr Noryati Abu Amin and Mr Junping Yu. Overall guidance was provided by the Coordinator, Patient Safety and Quality Improvement Unit, Dr Neelam Dhingra and the Coordinator of Service Organization and Clinical Interventions Unit, Dr Hernan Montenegro. Development of this publication was supported by Cooperative Agreement Number GH001180 from the United States Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of CDC. 1Introduction External quality assessment (EQA) is an important component of quality systems for blood transfusion services. EQA is the external assessment of a laboratory’s overall performance in testing exercise material of known, but undisclosed, content and comparison with the performance of other laboratories that have tested the same material. In laboratories that screen donated blood for transfusion-transmitted infections (TTI), participation in EQA helps to monitor and raise standards of performance. Information generated by EQA provides an opportunity for continual quality improvement through the identification of laboratory errors and the implementation of measures to prevent their recurrence. Thus EQA plays a vital role in making blood safer. The World Health Organization (WHO) plays an advocacy role in promoting the establishment of national EQA programmes and encourages participation by TTI screening laboratories in these programmes. National health authorities are urged to recognize the importance of EQA and support the implementation of these programmes throughout a country’s TTI screening network. Professional bodies are encouraged to endorse and support the establishment of EQA programmes. Establishing external quality assessment programmes for screening of donated blood for transfusion-transmissible infections: implementation guide aims to support WHO Member States in establishing and operating EQA programmes for screening donated blood for TTI. The guide has been designed for use by national health authorities and EQA organizing institutions in the development of EQA programmes that can be implemented at national, state, provincial and district levels. It will also give participating laboratories an insight into the organization of EQA programmes for TTI screening and an understanding of the benefits of participation. This guide is intended to be a companion to the WHO publication External quality assessment of transfusion laboratory practice: guidelines on establishing an EQA scheme in blood group serology (WHO/EHT/04.09). Hence, much of the present guide mirrors the information included in the earlier publication. This is because general principles of external quality assessment are the same irrespective of discipline. The scope of the guidance described here includes mandatory serology screening of all blood donation for HIV, hepatitis B and C, and syphilis. 2I N T R O D U C T I O N It may also be used to guide implementation of EQA for other agents for which mandatory screening is required in a particular country or region.1 Although screening for HIV, hepatitis B and hepatitis C using nucleic acid testing is undertaken in some Member States, establishing an EQA programme for nucleic acid testing is outside the scope of this guidance, as it would require different approaches to sample acquisition, characterization and analysis, additional infrastructure and stringent logistical conditions. This guide is designed to support the establishment of EQA programmes by organizing institutions that are in different stages of development. A phased approach should be considered if it is not possible initially to implement all the elements described here. The establishment of even a basic, small programme can have a significant impact in raising standards. When establishing an EQA programme in TTI screening, assessment of the most clinically important tests should be included first; the range of tests assessed can then be expanded as the programme is further developed. The guide describes the principles for establishing and operating an EQA programme for TTI screening. EQA programmes should be organized in accordance with these principles, although due consideration should also be given to regulatory and quality system mechanisms that may exist within a country for laboratories conducting TTI screening. 1 Screening donated blood for transfusion-transmissible infections: recommendations. Geneva: World Health Organization; 2010. 31 External quality assessment The transfusion of safe, compatible blood and blood products involves a number of processes. There is a risk of error in each process from the selection of blood donors, the collection, processing and testing of donated blood, the testing of specimens from potential transfusion recipients, and the issue of compatible blood and its administration to the recipient. The laboratory plays a key role in this transfusion chain and quality system failures in screening donated blood for TTI can have serious implications for the recipients of blood and blood products. Haemovigilance programmes, such as the Serious Hazards of Transfusion (SHOT) programme in the United Kingdom, have shown that laboratory errors can lead to major morbidity and mortality in transfusion recipients. Errors in the laboratory may be due to a number of deficiencies, including:  inadequate procedures for identification of donor specimens  incorrect storage or use of inappropriate reagents  inadequate equipment maintenance  poor testing practices  inaccuracies in recording or transcription  inadequate procurement practices  inadequate staff training. Errors often result from a combination of factors, with the original error being compounded by inadequate checking procedures in the laboratory. The aim of screening donated blood for TTI is to provide safe blood and blood products for transfusion. The implementation of a quality system in the TTI screening laboratory seeks to ensure this aim is achieved by minimizing errors. Accurate screening for TTI is essential for providing safe blood and blood products. Along with the performance of a test, it is equally important that the results are transcribed, collated and interpreted correctly so that safe blood products are issued for transfusion. 1.1 EQA AS PART OF A QUALITY SYSTEM IN THE SCREENING OF DONATED BLOOD FOR TTI External quality assessment forms an integral part of the monitoring of the overall quality system in a laboratory in which TTI screening is performed. National authorities should determine the standards with 4S E C T I O N 1 which quality systems in laboratories should comply. These standards can be developed nationally based on international standards or relevant international standards can be applied. The key elements of a quality system are:  organizational management, including: — quality policy and plan — clear organizational structure — designated individual(s) with responsibility for establishing and managing the quality system — job descriptions for all staff;  accurate and complete documentation, including standard operating procedures, and a functioning document control system;  training, mentoring and continued professional development of staff;  equipment validation, maintenance and calibration;  validation of reagents, consumables, techniques and, where applicable, software;  assessment, including: — internal quality control — internal and external audit — external quality assessment. 1.2 ASSESSMENT Continuous quality improvement requires ongoing monitoring and review of the effectiveness of all elements of the quality system, using both internal and external mechanisms, to ensure that the defined quality standards are being met consistently. Internal assessment of the quality system in the laboratory includes:  full validation of all activities, processes, procedures, equipment, reagents and software prior to their introduction and use;  regular monitoring of all critical activities where continuous measurement of the outcomes is both possible and appropriate.  use of specific control measures, such as quality control samples, to monitor the performance of critical activities;  staff competency assessment;  development of an internal audit system, using relevant standards or other regulatory and licensing requirements;  development of a system for the reporting, investigation and analysis of errors, with effective corrective and preventive action. External assessment of the quality system in the laboratory includes:  participation in an appropriate EQA programme;  external audit by a recognized independent body. Documentation: Written policies, instructions and records involved in providing a product or service. Standard operating procedure: Specified way to carry out an activity or a process that is documented, implemented and maintained – ISO 9000:2006 Internal quality control: Procedures that verify the attainment of the intended quality of results – ISO 15189:2013. These may include procedures to monitor the day-to-day reproducibility of test results and detect major errors in the analytical process. Audit: Systematic, independent and documented process for obtaining evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled – ISO 9000:2006. Effectiveness: Measure of the extent to which planned activities are realized and planned results achieved – ISO 9000:2006. Validation: Confirmation and provision of objective evidence that the requirements for a specific intended use or application have been fulfilled – ISO 9000:2006. Competency assessment: Process to assess an individual’s ability to apply knowledge and skills. E X T E R N A L Q U A L I T Y A S S E S S M E N T 5 1.3 EXTERNAL QUALITY ASSESSMENT Participation in EQA programmes is one of several effective mechanisms for identifying deficiencies or improvement opportunities within a laboratory’s processes and periodically provides an objective view of performance relative to that of other laboratories. Other EQA mechanisms include monitoring through supervisory visits or audits or sample exchange programmes. In the latter, materials are exchanged between laboratories and tested in a coded fashion. The results are analysed to determine whether all laboratories participating in the sample exchange achieve the same results. Participation in EQA involves testing sets of exercise materials of known, but undisclosed, content that are sent to participating laboratories by the EQA programme provider. Each participating laboratory receives an identical set of exercise materials, which should be processed in the same way as routine blood donor specimens to ensure that the laboratory’s performance in EQA accurately reflects its usual performance. Once the EQA exercise materials are tested, participating laboratories send the test results obtained back to the EQA programme provider. Following the collation and analysis of results, each laboratory receives feedback on its own results, together with the anonymized results for all other participating laboratories and the reference results, which enables it to compare its performance with that of other participants. The assessment of performance through EQA enables a laboratory to determine either that their systems are operating effectively or that deficiencies exist that require correction. As a result, corrective and preventive measures can be implemented as necessary. Thus, information generated by the programme helps to improve the overall quality of the laboratory and the safety of the blood and blood products it issues for transfusion. Even if a complete quality system is not in place, EQA can still be introduced as part of a process of continual quality improvement. 1.4 OBJECTIVES AND BENEFITS OF EQA The overall objective of EQA is to measure, maintain and improve as necessary the standards of performance in laboratories. Support for the national adoption of EQA can be achieved by raising awareness of the need for improvement, demonstrating the benefits of best practice, and providing information, education and support for improvement. Benefits to participating laboratories The benefits of EQA to participating laboratories include:  identification of opportunities for improvement relating to laboratory processes;  comparison of a laboratory’s own performance with that of other participating laboratories;  comparison of performance between different testing systems;  provision of information and education to improve performance;  encouragement of best practice; 6S E C T I O N 1  opportunities to enhance the credibility of the laboratory and increase public confidence;  access to a network of laboratories for the exchange of information. Benefits to health and regulatory authorities The benefits of EQA to health and regulatory authorities include:  establishment of a network of blood transfusion laboratories with a known standard of performance;  training and education of laboratory staff;  provision of useful information to assist in: — setting standards — reviewing testing strategies — postmarket surveillance of test kits, reagents, instruments — using resources effectively — improving public confidence in the blood transfusion service — supporting systems of accreditation. EQA is most effective in raising standards when the need for quality is recognized. This must be accompanied by commitment from senior management to support the changes needed to improve performance. Participation in EQA can be an effective means of driving quality forward in situations where quality systems are not in place. EQA results can reveal poor performance and assist in identifying the need for standards, guidelines, education and training, and the resources required to support them. 1.5 EQA PROGRAMMES EQA should be organized as a formal and structured programme to ensure effective planning and organization. This will ensure the uniform provision of exercise materials for testing and a standardized approach to both the analysis and reporting of results and the monitoring of performance of participating laboratories. If it is possible for the EQA organizing institution to be accredited to or comply with the principles of ISO/IEC 17043:2010, Conformity assessment: general requirements for proficiency testing, this will assist in achieving the standardization required. EQA should be made available to all laboratories in which TTI screening is performed, regardless of their size, workload or the complexity of the tests performed. Depending on the policy and regulatory systems in place, laboratories could participate in EQA on either a voluntary or a mandatory basis. Where participation is voluntary, laboratories should be actively encouraged to register for EQA all tests that they routinely perform. Figure 1 shows one model for a network of EQA programmes developed at international, regional and national levels. At each level, the programme provides the EQA exercise materials, advice and support to its participating laboratories and, in turn, has its own performance monitored through participation in another EQA programme. Another model may encourage TTI screening laboratories to participate in as many EQA programmes as is feasible to challenge their systems as comprehensively as possible. Accreditation: Procedure by which an authoritative body gives formal recognition that an organization is competent to carry out specific tasks – ISO 15189:2013 E X T E R N A L Q U A L I T Y A S S E S S M E N T 7 Nevertheless, in this model, the principle of the EQA organizing institutions having their own performance assessed still remains paramount. Based on country needs, WHO advocates establishment of EQA programmes at the regional, national or provincial levels with the aim of facilitating participation by all laboratories undertaking TTI screening of blood donors, irrespective of the type of institution with which they are associated. When establishing an EQA programme, it can be helpful to seek information and support from WHO or other well-organized EQA programmes. At national level, it is advisable to investigate existing EQA programmes in other areas of pathology and the possibility of sharing of organizational infrastructure, facilities and resources. Figure 1: Network of EQA schemes Blood transfusion services City / State / Provincial / District Regional International National Hospital blood banks Other laboratories International 82 Establishing EQA programmes for TTI screening The establishment of an EQA programme could be initiated by the national health authority, blood transfusion service, professional body or interested individuals. An organizing institution and a team of individuals within the institution should be identified to manage and operate the programme. An advisory committee should be constituted to oversee the establishment of the programme and provide guidance on planning and organization. An effective EQA programme requires the commitment and support of the national health authority or authorities, professional bodies, the organizing institution and relevant staff, the supplier of material for EQA exercises and participating laboratories. The success of the programme depends on the trust and cooperation of all involved. In particular, the involvement of participating laboratories is vital in the organization of the programme. The roles and responsibilities of all involved should be clearly defined in order to ensure the effective operation of the programme. 2.1 ORGANIZING INSTITUTION The organizing institution should be a reputable institution with suitable facilities and expertise in the relevant field. Ideally the institution should be designated by the ministry of health and have access to funds allocated specifically for the operation of the EQA programme to ensure the programme’s independence and sustainability. Organizing and managing an EQA programme requires a large commitment of time and must therefore be adequately recognized and resourced if the programme is to be successful. To avoid any conflict of interest, an organization with commercial interests in supplying laboratory equipment or reagents should not be designated as the organizing institution. Establishing an EQA programme provides an opportunity for the organizing institution to become part of a network of laboratories for the exchange of information; this may also bring recognition to the institution. The organizing institution should participate in a recognized international or regional EQA programme in the relevant field. It should be able to demonstrate satisfactory performance and also show that an effective quality system is in place. The organizing institution should strive for international accreditation to ISO 17043:2010: Conformity assessment: general requirements for proficiency testing. E S T A B L I S H I N G E Q A P R O G R A M M E S F O R T T I S C R E E N I N G 9 The facilities and resources required to implement an EQA programme include:  space  different test kits and methodologies  access to supplemental or confirmatory testing  equipment  staff  technical support  administrative support  reliable source of exercise material  information management system  adequate funding. Ideally, all the required facilities and resources will be provided by the organizing institution. However, it is important to avoid compromising the quality of the programme by attempting to obtain all the resources from within one institution, if this is not feasible. If facilities such as logistical support need to be sought from different institutions for an EQA programme, an effective system of coordination will be required. Within the organizing institution a team of appropriately qualified individuals with a designated leader (EQA programme team leader) should be dedicated to providing the EQA programme. (Hereafter this team of individuals will be referred to as the EQA programme provider.) The EQA programme provider should have extensive experience and knowledge of best-practice TTI screening, and be aware of common approaches in different types of laboratories. In-depth knowledge and understanding is crucial to ensure the planning of effective exercises, as is insight into possible causes of error and ability to offer effective advice when required. Responsibilities The EQA programme team leader is responsible for the general management, operation and ongoing development of the programme, including the following activities: 1. General management:  identifying the number of staff required and their training needs;  selecting staff and allocating staff time;  financial management of the programme;  convening advisory committee meetings;  communicating with suppliers, participating laboratories, the advisory committee, regulatory authorities, the media and, where applicable, accreditation authorities;  selecting laboratories to conduct confirmatory testing or validate programme exercise material if necessary;  ensuring the provision and use of a suitable information management system (manual or computerized) for the programme to collate participant information and results; 10 S E C T I O N 2  implementing, maintaining and auditing the programme’s quality system;  preparing annual reports;  preparing annual financial statements if necessary;  handling complaints and taking corrective action;  attending and presenting data at meetings of participating laboratories and conferences;  promoting the programme. 2. Operation of the programme:  devising exercises and sourcing exercise material;  distribution of the exercise materials;  keeping track of results return and sending reminders;  verifying data entry, analysing results, assigning scores and preparing individual and composite reports;  reporting to participating laboratories any identified problems and advising on ways of improving performance;  providing troubleshooting advice to participating laboratories;  reporting to the ministry of health on de-identified laboratory performance and any issues with policy implications;  monitoring trends in laboratory and test kit performance;  maintaining up-to-date information about participating laboratories. 3. Ongoing development of the programme:  keeping up to date with developments in transfusion laboratory practice in TTI testing;  initiating and implementing changes, as required, to ensure the continued relevance of the programme;  exploring improved methods for data management and provision of information;  developing the education and training function of the programme. 2.2 ADVISORY COMMITTEE An advisory committee is invaluable in the design, planning and implementation of the programme. The membership of the advisory committee should comprise:  EQA programme team leader;  selected experts in the relevant discipline;  representatives of: — national blood centre — participating laboratories — professional bodies — confirmatory laboratories, if used — health and regulatory authorities. Once the EQA programme is established, the advisory committee should continue to give direction for its effective continuation. E S T A B L I S H I N G E Q A P R O G R A M M E S F O R T T I S C R E E N I N G 11 To ensure effective decision-making and communication, the size of the committee should be limited and members who will participate actively should be selected. The number and timing of advisory committee meetings will depend on the size of the programme and the frequency of the distribution of exercises, but at least two meetings per year will be required. The committee should make annual plans in advance for the aims of the exercises to facilitate the procurement of exercise material. Members of the advisory committee should maintain confidentiality of programme information, including any details about the exercises, especially if their own laboratory participates in the programme. Functions and responsibilities The functions and responsibilities of the advisory committee include: 1. Setting policy on:  strategy and direction of the programme;  rules of participation;  analytes and markers to be included for assessment;  ensuring regulations are in place for safe transport of exercise material;  principles of scoring and defining poor or unsatisfactory performance;  action to be taken on unsatisfactory performance;  reviewing complaints;  actions to be taken to rectify lost or damaged panels;  promotion of the programme;  role of the programme in education and training;  providing a source of independent expert advice to help poorly performing laboratories. 2. Providing professional and scientific guidance on operational matters, including:  planning the aims of each exercise;  establishing the algorithms by which exercise material is characterized;  establishing the methods by which the reference results are determined;  agreeing on the content of reports;  reviewing laboratory performance in each survey;  dealing with specific questions;  reflecting the views of participating laboratories;  promoting the educational and training role of the programme. 2.3 TECHNICAL AND ADMINISTRATIVE SUPPORT Adequate technical and administrative support is required to ensure adherence to the EQA programme schedule. This may be obtained within the organizing institution by the redesignation of existing staff, 12 S E C T I O N 2 the appointment of suitably qualified staff or by contracting to outside agencies. Technical and administrative tasks include:  acquiring and characterizing material;  processing material;  testing exercise material to ensure its suitability and documenting the results;  dispensing and labelling exercise material;  packing and dispatching questionnaires, exercises and final reports;  organizing couriers and postal services;  entering and analysing results and other information;  invoicing participating laboratories for registration fees, if applicable. 2.4 INFORMATION MANAGEMENT SYSTEM The requirements for information processing will depend on the scale and scope of the programme. It is possible to operate an EQA programme without any information technology, but the use of a computerized system makes essential tasks such as producing results forms much easier and allows for a more complex analysis of results. It is essential to be able to:  create a database (manual or electronic) of the details of participating laboratories, including contact names, addresses, confidential registration codes and tests to be assessed;  prepare exercise documentation, including letters, instructions, results forms and address labels;  record the results from participating laboratories, using confidential registration codes;  perform basic analyses, including comparison of each individual participating laboratory’s results with the expected results and the collation of the overall results;  analyse results within defined groups, such as laboratories using a particular technique;  prepare reports with the expected results, the individual results of each participating laboratory and other overall analyses or comments. It is desirable to be able to:  report data in different formats, such as histograms and scatter charts;  generate scores for performance monitoring and cumulative scoring;  search the database using specified criteria. Specialized computer software is available or can be developed, but many of these functions can also be achieved by the use of standard commercial software packages. E S T A B L I S H I N G E Q A P R O G R A M M E S F O R T T I S C R E E N I N G 13 2.5 FINANCES The resources required to establish and operate an EQA programme must be identified, the costs estimated and funding sought. Tables 1 and 2 show the broad categories of capital and recurrent costs and examples of the facilities and resources required for the establishment and operation of an EQA programme. Possible sources of establishment funding include government, health authorities, professional bodies, nongovernmental organizations and organizations providing research funds. A regular source of funds will be required for the ongoing and successful operation of the programme. An EQA programme could recover all or part of the operational costs by charging a fee to participating laboratories. While paying a fee may make participating laboratories appreciate the programme, the fee amount needs to be such that it is not a barrier to a laboratory’s participation. Health authorities should allocate adequate resources to ensure the programme’s sustainability, allowing the contribution from laboratories to be affordable. Care should be exercised if commercial companies are involved, as the programme should be seen to be independent. Category Examples Accommodation  Purchase or lease of premises or modifications to an existing building for: — office — laboratory — cold storage — packing and distribution facilities — record storage Staff  Recruitment  Initial training, if necessary Capital equipment  Laboratory: — water purification system — centrifuge — incubator — refrigerator — freezer — TTI test kit-specific equipment, e.g. microtitre plate washer and reader  Processing and dispensing: — magnetic stirrer — lyophilizer (optional) — laminar flow cabinet — clamp stands — pump — racks  Storage, package and dispatch: — cold room or refrigerator — heat sealer  Office: — photocopier — telephone — fax  Information technology: — computer Table 1. Initial capital costs 14 S E C T I O N 2 Pilot study  Raw material and staff time for: — study design — processing — dispensing and dispatch — analysis and reporting IT consultancy (optional)  Design of software programs for: — registration — invoicing — analysis of results — production of reports Category Examples Accommodation  Rent  Maintenance  Overheads Staff  Salaries and benefits  Training and education  Travel and related costs  Conference fees Equipment  Maintenance contracts  Replacement and repairs Exercise material  Raw material — acquisition — processing, including filtration Laboratory testing  Reagents  Consumables, e.g. tubes and pipettes Office  Telephone  Stationery  Consumables for printing and photocopying Information technology  Development of software  IT support  Internet connection Dispensing, packing and dispatch  Bottles  Packaging  Postage, courier Meetings  Advisory committee  Annual meeting of participants  Workshops Consultancy fees  Statistician  IT development  Transfusion specialist 2.6 QUALITY SYSTEM OF THE EQA PROGRAMME It is essential that the EQA programme itself has a good quality system. Elements of the organizing institution’s own quality system could be utilized for this purpose. It will, however, be necessary to implement a specific, effective quality system for the programme, with a quality policy stating how it will provide EQA services to meet the needs of participating laboratories. This policy should be included in the programme’s quality Table 2. Continuing recurrent costs E S T A B L I S H I N G E Q A P R O G R A M M E S F O R T T I S C R E E N I N G 15 manual, with references to all processes and procedures in the quality system, including those specific to the EQA programme and those in common with the organizing institution. There are a number of different processes involved in organizing an EQA programme. Therefore, it is important to ensure that appropriate documents and records for each step of the programme exercise are generated for traceability. These include quality plans, standard operating procedures, production protocols, worksheets, checklists, forms, exercise material characterization results, test kit interpretations, and details and results reported by participating laboratories. All documents and records must be kept confidential, stored securely and be readily accessible. The EQA programme provider may consider the following mechanisms to demonstrate quality of processes:  WHO/CLSI/CDC Laboratory quality management system: handbook  ISO 15189:2012 Medical laboratories: requirements for quality and competence  ISO 17043:2010 Conformity assessment: general requirements for proficiency testing  ISO 9001:2008 Quality management systems: requirements  ISO 17025:2005 Accreditation for testing and calibration laboratories  Continuing and satisfactory performance in an appropriate international EQA programme. 2.7 PARTICIPATING LABORATORIES When organizing an EQA programme, the advisory committee should define the profile of laboratories that should be encouraged or required to participate. The programme should be actively promoted to encourage full participation, but the most effective mechanisms for promotion will depend on whether it is a voluntary or mandatory programme. It is important to be aware of the number and type of laboratories that intend to participate, as this will have an impact on the organization of the EQA programme. Potential participating laboratories should be sent a preliminary questionnaire to identify:  staffing levels  overall workload  range of tests routinely undertaken  techniques and reagents used  quality system in place. This information can be used to ensure a suitable design for the format of EQA exercises (section 4) and may be also be useful for categorizing laboratories for performance monitoring (section  6). An example of a preliminary questionnaire to obtain general information about participating laboratories is included as Annex 1. 16 S E C T I O N 2 2.8 PILOT STUDY A pilot study should be undertaken to test the structure of the EQA programme, proposed methods of operation and design of exercises. The purpose of a pilot study is to expose any unforeseen logistical problems and identify solutions before scaling up the operation of the programme and offering formal participation. At least two pilot exercise distributions should be sent to a limited number of participating laboratories. These laboratories should be selected to represent different groups of participants in terms of their distance from the organizing institution, the size of their laboratories or the techniques they use. Participating laboratories should be asked to comment on any problems they encountered and to make suggestions for improvement. At the completion of the pilot study, a review should be made of problems experienced in the operation of the programme and comments from participants. Adjustments can then be made to the design of the programme and to the estimate of operating costs, if necessary. 2.9 PRACTICAL STEPS IN ESTABLISHING AN EQA PROGRAMME An outline of the practical steps to be taken in establishing an EQA programme is shown in Figure 2. Detailed discussion of each of these steps is found in the ensuing sections. E S T A B L I S H I N G E Q A P R O G R A M M E S F O R T T I S C R E E N I N G 17 Figure 2. Steps in establishing an EQA programme Identify organizing institution Identify organizing institution Identify established EQA programme for advice and support Set up advisory committee Identify source(s) of funds Identify potential participating centres Identify source and storage of exercise material Send preliminary questionnaire to all potential participating centres Invitation letter Design exercise format, based on information provided Identify distribution mechanism Conduct pilot study Develop systems for preparing and distributing exercises, handling results and performance monitoring Evaluate pilot study and make modifications, if necessary Promote the programme and register participating laboratories Implement the programme Monitor and evaluate the programme 18 3 Participating laboratories In order to participate effectively in an EQA programme, participating laboratories should recognize the need for quality and the role of EQA within a quality system in the TTI screening laboratory. Understanding the benefits of EQA and the way in which the programme works will encourage compliance with the rules of participation. This will enhance the value of the programme to the individual participating centres and the overall quality of the information generated. All staff in participating laboratories should have access to the EQA reports distributed by the programme. Any problems identified should be discussed openly in regular meetings and dealt with as problems relating to laboratory procedures and practices rather than as criticism of individual members of staff. Analysis of the root causes of errors in EQA provides the opportunity for participating laboratories to implement changes to prevent similar errors being made. Once the programme is established and open to participation, a formal registration process is required in order to gather contact details and other essential information from participating laboratories and also to provide them with the information they need for effective participation. This information should be provided in the form of an EQA programme information manual. The EQA programme provider may also consider organizing seminars for potential participants to explain the programme. 3.1 EQA PROGRAMME INFORMATION MANUAL An information manual should be developed to explain the management and operation of the programme and give practical instructions for participation. The information manual should be distributed with a registration form. The information manual should include:  aims of the EQA programme;  description of and contact details for the EQA programme provider;  details of the advisory committee;  explanation of the commitment needed from participating laboratories and the benefits of participation;  rules of participation;  description of the exercises offered;  explanation of the performance monitoring and scoring system; P A R T I C I P A T I N G L A B O R A T O R I E S 19  definition of unsatisfactory performance and action to be taken in the event of unsatisfactory performance. 3.2 RULES OF PARTICIPATION Clear rules of participation in the programme should be determined by the advisory committee. These rules should set out:  what is expected of participating laboratories;  the service to be provided by the programme;  how the information collected, including performance data, will be used. Participating laboratories should agree to these rules at the time of registration. Examples of rules of participation are given in Boxes 1 and 2. To maximize the benefit to participating laboratories and ensure the validity of programme data:  Only those techniques and technologies that are used in routine algorithms should be used to test the EQA exercise material.  EQA exercise material should not be tested only by the most senior or experienced staff.  EQA exercise material should be tested alongside routine specimens; it should not be kept aside for testing separately.  Exercise material should not be tested more than once and the results compared unless all specimens are also routinely tested in this way.  Excess exercise material may be used for other purposes such as staff training or competency assessment once the EQA results have been submitted.  Results must be returned by the closing date specified for the exercise.  There must be acceptance of agreed procedures for performance monitoring and follow-up of unsatisfactory performance.  Copyright of programme data must be observed to ensure that they are not published or presented out of context; permission must be sought from the programme provider or advisory committee before data are used. Box 1. Example of rules for laboratory participation in an EQA programme 20 S E C T I O N 3 To ensure the effective operation of the programme:  The confidentiality of performance data must be maintained between the programme provider, the advisory committee and the participating laboratory, unless there is an obligation by legislation or prior agreement for them to be disclosed to a third party.  Exercise material provided should have reliable quality.  There must be a clear time scale for the distribution of exercises and the return of the report.  The exercise material must be safe.  EQA programme reports must include suggestions for improving performance.  The EQA organizer must be available to address participating laboratories’ questions or concerns.  Exercise material must not be sent to another laboratory for testing, or communication entered into with another participating laboratory about the results. 3.3 REGISTRATION At registration, all interested laboratories should be sent a registration form, together with the information manual. The registration form should request the following information:  Contact details for the delivery of exercise materials and reports: — name of the participating laboratory — name of contact person — full postal address — telephone number — fax number — email address, where available.  The name and address of an additional person such as the head of participating laboratory or institution may be given for correspondence regarding performance, if required.  The relevant tests used by the participating laboratory and on which it wishes to be assessed should be included, enabling the programme to identify the tests for which exercise results can be expected from each laboratory. Ideally, participating laboratories should be assessed for all tests that they routinely perform. The registration form should also include a section to be signed by the participating laboratory, indicating its agreement to abide by the rules of participation. Examples of registration forms are included in Annex 2. Each participating laboratory should be allocated a confidential registration code for use in correspondence with the programme to ensure confidentiality of results and performance data. This code and the information on the registration form for each laboratory should be entered into the programme’s information management system. If a Box 2. Examples of rules for the programme P A R T I C I P A T I N G L A B O R A T O R I E S 21 computer database is used, each component of these details (such as the registration code and each line of the address) should be entered as separate fields to facilitate searches on the data. Information on participating laboratories should be kept up to date by annual re-registration; a new registration form should be distributed with a copy of the current registration details for confirmation. This will enable the programme to obtain updated technical information and contact details. 22 4 Practical considerations in establishing an EQA programme Information obtained from the preliminary questionnaires completed by potential participating laboratories should be used to design EQA exercises. Whenever possible, each EQA exercise should have an educational function, exploring areas where wide variation in testing is known to occur or suspected to be challenging to laboratories. The following practical aspects of the programme should be considered during its design:  scope  EQA programme and exercise format  objectives of the programme  sourcing and processing exercise material  exercise documentation  analysis and communication of results. 4.1 SCOPE A TTI EQA exercise should meet the needs of the participating laboratories and assess the tests routinely performed for screening of donated blood. This can be ascertained from the laboratories’ responses to the preliminary questionnaire. Screening for markers such as HIV-1/2 antibodies, hepatitis C antibodies, hepatitis B surface antigen and Treponema pallidum antibodies may be considered standard in a TTI laboratory and therefore should be included in EQA programme exercises. Depending on the scope of testing of the participating laboratories and the national regulatory requirements for screening of TTI, the markers included may be expanded to include HIV-1 p24 antigen, hepatitis B core antibodies or other markers such as Trypanosoma cruzi, malaria and HTLV-I/II antibodies. 4.2 EQA PROGRAMME EXERCISE FORMAT The number of EQA exercises to provide in a year should be sufficient to allow adequate assessment of laboratory procedures and practices and to gather sufficient data for cumulative performance monitoring. At least two exercises should be distributed to participating laboratories each year to give a minimum level of confidence in the laboratories’ performance. P R A C T I C A L C O N S I D E R A T I O N S I N E S T A B L I S H I N G A N E Q A . . . 23 The number of exercise materials that will be included in an EQA exercise should enable detection of potential errors in laboratory processes. An exercise consisting of a small number of materials (for example 1–4) may be able to detect random errors but will have limited capacity to detect systematic errors. Panels that consist of a larger number of exercise materials (for example 5–10) will have greater capacity to detect both random and systematic errors. 4.3 EQA PROGRAMME OBJECTIVES Each EQA exercise should address specific questions or objectives; the EQA panel should be constructed to address these objectives. A good EQA programme will provide participating laboratories with education on good laboratory practice and will be able to identify different laboratory errors that may occur. Some possible objectives and mechanisms are shown in Table 3. Objective Mechanism Can the participating laboratory correctly identify the status of specimens? Do the participating laboratory’s results match the reference results? Does the participating laboratory follow the manufacturer’s kit protocols? Collect details of testing on the results form, for example variations in test kit control results, reading time Does the participating laboratory produce consistent results? Include replicates of the same exercise material Does the participating laboratory produce consistent results over time? Include replicates of the same exercise material over different exercises Does the participating laboratory have a process for rejecting unsuitable specimens? Include haemolysed or other unsuitable exercise materials and assess if the participating laboratory proceeds to test the materials Can the participating laboratory identify administrative errors? Include exercise materials that have been purposely mislabelled Compare performance of different testing systems Analyse the results according to different systems and technologies Verify coverage of mandatory screening for TTI Include all mandatory markers Check the laboratory report 4.4 SOURCES OF EXERCISE MATERIAL Exercise material should preferably be obtained from blood transfusion services, since donor blood is ideal as exercise material. It is readily available in large volumes and is tested for TTI in accordance with local regulations. However, the ethics surrounding its use should be clarified. Ideally, informed consent should be obtained from the donors to use their blood for EQA purposes. Finding the required number of donations positive for TTI could prove to be difficult. When no suitable donor material is available and patient material has to be used, informed consent must be obtained. Table 3. EQA programme objectives and mechanisms Exercise materials: Materials that have been prepared from samples and that make up an EQA panel. Panel: A set of EQA exercise materials. Sample: A specimen, preferably of large volume, that has been processed, tested, and stored in a sample bank for potential use as exercise material. Specimen: Discrete portion of a body fluid, breath, hair or tissue taken for examination, study or analysis of one or more quantities or properties assumed to apply for the whole (ISO 15189:2013). 24 S E C T I O N 4 Blood transfusion service algorithms may prescribe that donations reactive on a TTI screening test kit are discarded, that is, confirmatory testing is not performed. In those cases, the reactivity may be true or false, and if the donations are to be used as exercise material, confirmation may be undertaken by the EQA programme provider or a designated expert laboratory. Efforts should be made to ensure that donations provided as potential exercise material confirm as positive when confirmatory testing is undertaken. This is important because of the costs involved in transporting plasma packs in accordance with regulations and in confirmatory testing. These investments are wasted if the reactivity of plasma packs is not as expected. Measures the programme provider can implement include:  Consider the prevalence of the TTI in the donor population from which the plasma packs are being sought. Preference should be given to obtaining plasma packs from blood transfusion services where the prevalence of the particular TTI is higher, so the positive predictive value of the reactive result in the screening test kit is higher.  Choose suppliers with good quality systems in place so that the quality of their test results can be trusted. Suppliers of exercise material should be selected according to their ability to make reliable provision of the quantity of material required and assure its quality. There should be a formal agreement between the EQA programme provider and the supplier or suppliers to ensure that the supply of exercise material is reliable and meets all the specifications set by the programme. It is essential that the EQA programme provider or an expert laboratory, if used, is able to characterize the exercise material accurately, even if participating laboratories are not required to undertake extensive testing (see section 5.3 on the selection of exercise material). Candidate samples for TTI exercise material may be organized into a “sample bank” – a repository of a large number of large-volume samples with varying characteristics. This is possible because, in the case of TTI, the most common exercise material is plasma or serum, which can be stored frozen for prolonged periods without compromising its serological reactivity. Significant and ongoing resources are required to establish and maintain a sample bank. 4.5 ESTABLISHING A SAMPLE BANK Establishing a TTI sample bank for serum or plasma to be used as exercise material should be commenced well in advance of the first EQA programme exercise. Candidate sera and plasmas should be processed in a timely manner and stored appropriately. Upon receipt, a unique laboratory identification number should be allocated to each serum and plasma. A candidate serum or plasma obtained in large volume should be dispensed into smaller practical volumes aimed at reducing the number of freeze/thaw cycles. Serum and plasma should be stored frozen at or below –20°C in polypropylene containers of appropriate volume with leak- proof screw lids containing a sealant such as an O-ring. P R A C T I C A L C O N S I D E R A T I O N S I N E S T A B L I S H I N G A N E Q A . . . 25 The containers should be clearly labelled using high-quality adhesive labels. The exercise material should be carefully characterized through validated testing strategies to determine the true serological status of the material, and the information stored in a database (see subsection on characterizing and testing EQA exercise material, in section 4.6). A sample bank database is an inventory of biological material in a repository. The information in the inventory should be updated on a regular basis, as it will need to be accessed each time an EQA exercise is planned. The type of information that should be recorded in a sample bank database includes:  unique laboratory identification number  reference number or code  date collected  date received  type of material (e.g. serum, plasma)  volumes and number of vials (if dispensed into smaller volumes)  clinical information and provider’s test results  characterization test results  location in sample bank freezer  sample tags2  number of freeze/thaw cycles. Once the sample bank is established, it is recommended that allocation of resources continues in order to maintain the appropriate number and volumes of exercise materials required for future EQA exercises. 4.6 PROCESSING CANDIDATE EXERCISE MATERIAL Although plasma is an appropriate biological material for TTI EQA exercises, there are aspects that must be considered when it is used as EQA exercise material (for example limitations in volume, and formation of clots regardless of filtration or centrifugation steps). In some cases defibrinated plasma or serum may be considered as an alternative to plasma. Which biological material to use as TTI EQA exercise material should take into account the needs of the participating laboratories and the validity of the material for use in TTI test methods. Manipulations may be performed to increase the volume or quality of biological materials used for EQA exercises. It should be stressed that EQA exercise materials should be as representative of “normal” donor specimens as possible. Each manipulation performed will cause deviation from “normality”. Further, a manipulation may have an adverse effect on the results produced by different test methods. Thus, each method of manipulation should be extensively validated for its effect before applying it to EQA exercise material. 2 It is useful to consider the allocation of a “tag” or code to each serum or plasma to help search and identify materials in the database. 26 S E C T I O N 4 Conversion of plasma to serum Plasma collected in donor collection bags will contain an anticoagulant such as citrate-phosphate-dextrose (CPD), and thus conversion to serum naturally is not possible. However, plasma can be converted to defibrinated plasma (in effect serum) by artificially initiating the clotting cascade through the addition of thrombin followed by removal of the resulting clot. Once the clot is removed, microfiltration of the serum should be considered to remove any bacterial contamination.3 Filtration Biological materials can be filtered using either vacuum or pressure filtration apparatus, in a stepwise reduction of pore size (prefilter, 0.8 microns, 0.45 microns and a final 0.22  microns). Filtration will remove any microparticulate matter, ranging from microclots to bacterial contamination.4 As a note of caution, the conversion of plasma to serum and filtration processes are cumbersome, labour intensive and potentially hazardous. Therefore, these processes should be conducted in biohazard cabinets by personnel with adequate personal protective equipment including gowns, gloves and face masks or goggles. Nevertheless, effort must be made to provide exercise material free of contamination, particulate material and clots. Without conversion of plasma to serum, reasonably satisfactory exercise materials can be produced by centrifugation of the material to remove particulate matter and clots. To maintain sterility without filtration, exercise material should be handled in a class II biosafety cabinet, paying attention to aseptic techniques to the extent possible and using sterile equipment and containers. Use of biocides The use of biocides may be considered to reduce the potential for bacterial growth and preserving the quality of the biological material. An example of a biocide is ProClin 300 (1.5% methylisothiazolinone, methylchloroisothiazolinone). Sodium azide, which was once used extensively as a biocide, is no longer recommended owing to safety concerns. Thorough validation of any biocide should be undertaken to identify potential interference with TTI test methods.5 Pooling For large EQA programmes, pooling can be considered an option for increasing the volume of exercise material available (where the volume 3 Ratnoff OD. “An accelerating property of plasma for the coagulation of fibrinogen by thrombin”, Journal of Clinical Investigation. 1954;33:1175–82. 4 Bobbitt JA, Betts RP. “The removal of bacteria from solutions by membrane filtration”. Journal of Microbiological Methods. 1992;16(3):215–20. 5 ProClin: http://www.sigmaaldrich.com/content/dam/sigma-aldrich/docs/SAFC/ General_Information/proclin_efficacy.pdf. P R A C T I C A L C O N S I D E R A T I O N S I N E S T A B L I S H I N G A N E Q A . . . 27 requirement for the number of participants exceeds that normally found in a single blood donation). Pooling samples involves mixing individual samples together to create a mixed pooled sample. However, in pooling samples, a dilution effect may be created – in other words, dilution of the individual constituents of each sample used in the pool. This risk may be reduced by selecting samples of similar antibody or antigen profiles, as ascertained by testing, thus only pooling samples with similar test result profiles or characteristics. Pooling has the benefit of extending the volume of exercise material while seeking to maintain the reactivity of key constituents in the samples contributing to the pool. Sometimes, pooled negative sera or plasmas can show an increased tendency to false reactivity. Therefore, pooled exercise materials, whether they are negative or positive, should be tested extensively before use in an EQA programme. Dilution Dilution with negative plasma or another isotonic diluent to create exercise materials should be avoided where possible. Dilution of biological material to increase the volume may be possible if the material is only diluted to the extent required to create the additional volume. Dilution to mimic early infection profiles or “weak” results creates a final exercise material that does not have a serological profile representative of that seen in undiluted donor specimens. In addition, the ability of some tests to detect diluted antibodies or antigens that would normally be detected when undiluted may be reduced. The EQA programme provider must test diluted exercise materials in a large number of test kits that are likely to be used in the programme to ensure that they behave as expected. Dilution of quantifiable markers – for example, hepatitis B surface antigen (HBsAg) or HIV-1 p24 antigen – may be considered as options to produce serological exercise materials representative of early infection, where it is difficult to find naturally occurring biological material of sufficient volume. In the case of HBsAg, care must be taken to not overdilute other early hepatitis B markers (anti-HBc IgM), should these be markers that the EQA programme is assessing. Further, the diluent must be free of hepatitis B surface antibody as it is likely to complex with HBsAg and render it unavailable in the testing system. Dried tube samples Transportation conditions are major contributors to poor-quality exercise materials. In addition, transportation costs may be too high, adding a financial burden to the EQA programme. Some EQA programmes for resource-limited settings are provided as dried tube samples (DTS). These are small volumes of positive or negative serum or plasma that have been dried in air over 12–24 hours.6 6 Parekh BS, Anyanwu J, Patel H et al. “Dried tube specimens: a simple and cost- effective method for preparation of HIV proficiency testing panels and quality control materials for use in resource-limited settings”. Journal of Virological Methods. 2010;163(2):295–300. 28 S E C T I O N 4 Only small volumes can be dried over this period (for example 20 microlitres), but the dried pellet is reconstituted in a ten-times greater volume, usually in phosphate-buffered saline, resulting in exercise material that is tenfold diluted and having a different matrix from true serum or plasma specimens. It is not advisable to use weakly positive samples in DTS EQA programmes because the dilution may cause false negative reactions in all or some test kits. The EQA programme provider must reconstitute and test the DTS in a large number of test kits that are likely to be used in the programme to ensure that the exercise materials behave as expected. Despite these different approaches that contravene conventional EQA norms, using DTS makes providing some form of quality monitoring possible in situations where conventional EQA programmes are not feasible. It must be noted that if DTS are provided as exercise materials for an EQA programme, the participating laboratories must reconstitute them before testing. This is an additional variable, the potential impact of which must be considered when analysing and scoring results. Characterizing and testing EQA exercise material The key attributes of exercise material in TTI EQA are:  that the specimen type is generally approved by the manufacturers of test kits that are used by the programme participants, for example serum or plasma;  that the exercise materials are homogenous, and stable for the period over which the exercise is under way;  that the true status of an exercise material is known for the markers under assessment. Instructions for use that accompany test kits for TTI usually specify the specimen types that are appropriate for use in the tests. It is important that the exercise materials provided in the EQA programme mimic as closely as possible a specimen type that is allowed by all the tests, otherwise aberrant results may be obtained if a specimen type differs significantly from those recommended. For example, as mentioned earlier, the appropriateness of phosphate-buffered saline reconstituted DTS as a specimen type must be confirmed by the programme provider as appropriate in all the test kits used by the programme participants. Characterization of samples is usually achieved using a testing strategy and a defined algorithm. A testing strategy defines the range and types of tests used to determine the status of a sample; an algorithm specifies the names of the tests and the order in which they are used. A testing strategy includes a first test to identify negative samples, and one or more supplemental tests that are used to confirm whether those samples that are reactive in the first test are positive or not. This confirmation of positive reactivity is performed because all tests for TTI give a small proportion of false positive results. Testing in a second test assists with ensuring that samples in the sample bank that are assigned a positive status are truly positive. The first test in an algorithm must be of high sensitivity, especially because it will identify negative samples, that is, a negative result from P R A C T I C A L C O N S I D E R A T I O N S I N E S T A B L I S H I N G A N E Q A . . . 29 the first test will be assumed to be correct and no other testing will be performed to “confirm” the material’s negative status before its status is assigned in the sample bank. Therefore the programme provider needs to be confident that the first test kit used to characterize sample bank samples is as sensitive as is available and will not misclassify positive samples that could be detected by other test kits used by laboratories participating in the EQA programme. The EQA programme provider needs to consider carefully the way sample bank samples are characterized. For example, if any participating laboratories have indicated that they use HIV combination assays, which detect both antibodies to HIV and HIV p24 antigen, the EQA exercise materials must be characterized for both of these markers. Similarly, if participating laboratories use specific or non-specific treponemal tests for syphilis, the status of the EQA exercise materials for both of these markers should be known. The key attributes to consider when choosing tests for characterization of samples and testing of EQA exercise materials are:  Tests available. Most countries will have a list of tests that can be procured for each marker.  Test characteristics. Information about a test’s performance (sensitivity and specificity), its ease of use, requirements for equipment, and other characteristics is necessary. Such information may be found on the WHO website.7 Peer-reviewed publications are another source of information.  Purpose of testing. An EQA programme provider may be performing testing for purposes other than characterization of EQA material. It is this testing that will drive the choice of tests, for example, what is the throughput of testing; what is the required turnaround time; what is the shelf life of the reagents; and is there access to refrigeration if necessary. 4.7 EXERCISE DOCUMENTATION Each EQA exercise requires accompanying documents, which may include:  instructions on how to handle, test and report results for the EQA exercise material;  results forms;  feedback questionnaires, included periodically to enable continual improvement of the programme. Exercise instruction sheets that are generated for each exercise should provide general information on how to handle, test and store the exercise materials and how to report the results to the EQA programme provider. The participating laboratories should be reminded to treat the exercise materials as routine specimens and subject them to the same testing and processes. The instruction sheets generally include the following information: 7 http://www.who.int/diagnostics_laboratory/evaluations/en/. 30 S E C T I O N 4  number and identifiers of exercise materials  exercise code  deadline date for returning the results  storage and handling instructions  testing instructions  reporting instructions  biological safety precautions  EQA programme provider contact information. An example of an exercise instruction sheet is given in Annex 3. The EQA programme provider should prepare a form for the collection of EQA exercise results. The EQA results form may be provided electronically or in paper form. Whichever mechanism is used, the form will allow for a standardized approach to collecting EQA test results and information from participating laboratories. A paper-based data collection form requires the EQA programme provider to design a results collection form that is sent to the participating laboratories with the exercise panel. Upon completion of testing for the exercise the laboratories must submit the completed results form to the EQA programme provider by mail or fax. This format is simple to develop and allows for flexibility in the information that can be provided by the participating laboratories. A disadvantage of paper-based data collection is that results from all of the participating laboratories must be collated by the EQA programme provider, a process that is time consuming and vulnerable to error. An electronic data collection form can be sent electronically to the participating laboratories. When the testing for the exercise is complete, the participating laboratory enters the results into the form and can return it to the EQA programme provider electronically. The EQA programme provider can then copy and collate the data electronically, reducing the time required for data entry. Although this format can reduce the likelihood of data entry error, validation checks are necessary to ensure that data have been copied accurately. A further adaptation of electronic data collection is an Internet-based format. This method requires the design and maintenance of an online data collection system. Participating laboratories can enter the EQA exercise results directly into the online database. In this format no data entry is required by the EQA programme provider, eliminating the time taken and potential for error at this step. A disadvantage of this data collection format is the need for resources to design and maintain a functional website. Furthermore, participating laboratories will require the information technology infrastructure to use the system. Whichever format is chosen for the collection of EQA exercise results, the results forms should generally include the following information:  participating laboratory code and name  receipt date and condition in which the exercise material was received  name of test method or reagents used P R A C T I C A L C O N S I D E R A T I O N S I N E S T A B L I S H I N G A N E Q A . . . 31  reagent lot number and expiry date  date of testing and name of person doing the test  test results and interpretations  additional comments. Examples of exercise results forms are given in Annex 4. 4.8 LOGISTICS Based on local infrastructure, the EQA programme organizer will need to decide upon the mode of transport for the EQA panels to be delivered to the participating laboratories. Health and safety issues should be considered for all groups of workers who may be exposed to exercise material, including postal and courier workers. These people must be trained how to handle the exercise material safely should the packaging be damaged or there is leakage. EQA programme exercises should be packed and labelled in conformity with local or international postal or air regulations, such as those of the International Air Transport Authority (IATA), as applicable. For IATA purposes, exercise materials can be shipped as diagnostic samples and not as dangerous goods. IATA regulations require specific triple packaging and labelling. In brief, vials containing exercise material are sealed in a watertight secondary package that contains sufficient absorbent material to soak up the total volume of exercise material within the package in case of leakage or breakage. The secondary package should be placed in further packaging that is capable of protecting the contents from physical damage while they are in transit (Figure 3). Figure 3. Schematic of triple packaging for IATA-compliant shipping of diagnostic samples The external packaging should be labelled to indicate that it contains pathological material. The name and address of the EQA programme should be written on the outside as well as the name and address of the participating laboratory to which the exercise material is being sent. Source: IATA, Montreal, Canada. 32 5 Planning and operating an EQA programme for TTI testing There are two types of plan required to guide the provision of an EQA programme. One is an annual plan, which describes the main features of the programme and the activities of the programme provider over a year of the programme. The other plan is a detailed description of the activities required from beginning of material production to the finalization of the EQA programme report. A plan of this type is required for each EQA exercise. 5.1 DEVELOPING AN ANNUAL EQA PROGRAMME PLAN Before the commencement of an EQA programme, the programme provider should identify and plan the processes for the EQA programme year. Plans should be documented and contain information that addresses the objectives and design for each exercise of the EQA programme year. Annual plans should contain references to standard operating procedures, protocols and other documents that contain more detailed information. Typically, annual plans for EQA programmes should address the following information:  name, address and contact details of the EQA programme provider;  name, address and contact details of subcontractors involved in the EQA programme, if applicable;  any specific objectives of the EQA programme for the year – for example, an annual objective could be to examine the laboratories’ abilities to obtain reproducible results on different occasions when testing the same materials;  activities to ensure samples in the sample bank are adequate to meet the needs for the year’s exercises;  the number and type of participants expected to be enrolled in the EQA programme;  participation fee or funding mechanisms;  information on what materials and analytes participating laboratories are to identify, measure or test for in each exercise of the EQA programme;  requirements for the production, quality control, storage and distribution of EQA exercise material; P L A N N I N G A N D O P E R A T I N G A N E Q A P R O G R A M M E F O R T T I . . . 33  schedules and dates for production of EQA exercises, dispatch to participating laboratories and deadlines for submission of results by participants;  procedures for homogeneity and stability testing;  description of the statistical analysis to be used if applicable and criteria for the evaluation of performance of participating laboratories;  expected dates when reference results and final reports will be made available to participating laboratories. 5.2 DEVELOPING THE PLAN FOR A SPECIFIC EQA EXERCISE While the annual EQA programme plan is a high-level document that defines broadly the attributes of the programme, a specific plan is required to guide the preparation of each EQA exercise. This more specific plan will document how each individual exercise will be executed. The specific plan should address the following information for each exercise:  responsibilities of individual staff in preparation of the exercise;  aim(s) of the exercise;  number of laboratories enrolled in the exercise;  selection criteria and volume requirements for each of the exercise materials to satisfy the aim of the exercise;  exercise name, panel number and code;  identifiers for individual exercise materials;  detailed production processes and verification testing;  schedule and dates for production of the exercise panels, dispatch to participating laboratories, and deadline for submission of results and report distribution;  references to protocols for homogeneity and stability specific to each exercise;  references to all documents, forms and records involved in the exercise. It is recommended that a process checklist and timeline be designed alongside the specific EQA exercise plan; this ensures that processes occur in a systematic manner and provides traceability of the entire EQA process. 5.3 SELECTION OF MATERIAL FOR EQA EXERCISES Appropriate samples that will satisfy the aims of the specific EQA exercise should be selected from the sample bank. Each exercise should contain materials that are of highest quality, each with a defined serological status, based on the characterization testing results recorded in the sample bank database (see section 4). An EQA exercise will consist of a number of negative and positive exercise materials. The number of negative and positive exercise materials and the order in which they are presented in the panel should vary from exercise to exercise to avoid the participating laboratories predicting the exercise composition. 34 S E C T I O N 5 Sufficient vials should be prepared to meet both the requirements of participating laboratories and to allow the programme provider to retain spare vials in storage. Spare vials are needed in case participating laboratories require replacements due to loss or breakage, or for repeat testing following an error. Additional vials will also be required by the programme provider for in-house testing throughout the duration of the exercise for stability purposes, for archiving or for future use. The total volume required for each exercise material is calculated by taking into consideration the following:  total number of participating laboratories in the exercise;  number of additional exercise panels that will be prepared (to be used as replacement panels or for investigation purposes);  number of vials of each exercise material required for homogeneity and stability testing;  volume required for each vial;  volume loss or error allowance during panel production (through centrifugation and dispensing). 5.4 PREPARATION OF EXERCISE MATERIALS Once appropriate samples have been identified, they are removed from the sample bank. The removal of the samples should be updated in the sample bank database. Samples will need to be thawed prior to use. For smaller volumes, plasma can be thawed in a water bath at 30–37°C, for as long as it takes to thaw (normally no more than 30 minutes). Thawing time will vary according to the temperature of the water bath and the volume of plasma.8 Once thawed, volumes of the same sample should be combined if the sample was stored in more than one vial. If pooled samples are to be used in the EQA exercise, the pooling process would take place during this stage. Separate aliquots of the same sample or aliquots of different samples identified for pooling must be well mixed before further processing. The total volume of each sample is centrifuged to pellet particulate matter and the supernatant decanted into a separate sterile vial. Each sample should be tested again before dispensing into individual vials to create exercise materials, and cross-checked with the original sample bank characterization results. This verifies that there has been no mix-up and that there has been no degradation during storage. If any results differ from those expected, the sample is not appropriate for use in the exercise and it is recommended to select an alternative sample. 5.5 DISPENSING EXERCISE MATERIAL Screw-capped external thread polypropylene vials of appropriate volume should be prelabelled prior to dispensing, with adhesive labels that have 8 Extended life plasma: a framework for preparation, storage and use, 2nd edition. Australian and New Zealand Society of Blood Transfusion Ltd; 2013. P L A N N I N G A N D O P E R A T I N G A N E Q A P R O G R A M M E F O R T T I . . . 35 been validated to demonstrate adherence to the vials through fluctuating temperatures and storage conditions. Adhesive vial labels should contain the following information:  EQA programme name  exercise number or code  identifier of the exercise material  volume of the material contained in the vial. It is recommended that the information on the labels be printed electronically if possible to minimize transcription errors. Labelling of all tubes for one exercise material should be segregated to avoid mix-up of labelled tubes. Dispensing all the vials for one exercise material should be completed before moving on to the next to reduce the risk of contamination, of mix-up between materials, or of dispensing into an incorrect vial. It is recommended that negative materials be dispensed first followed by positive materials. Manipulation of biological material is ideally performed inside a biological safety cabinet. Once exercise materials are dispensed into vials, the panels can be assembled into labelled panel packaging. Packaging labels should contain the following information:  EQA programme name  exercise number or code  number of exercise materials in the panel  recommended storage temperature  expiry date  biohazard symbols. The assembled exercise panels should be stored between 2°C and 8°C until ready for dispatch, which should occur as soon as possible after the production has been completed. 5.6 VERIFYING HOMOGENEITY AND STABILITY Regardless of the biological material used, it is necessary to ensure that exercise materials are adequately mixed and all participating laboratories receive equivalent material that is uniform in composition with minimal variation (homogeneous material). Verification of the materials’ homogeneity should be completed for each EQA exercise distribution. It is performed:  by testing a random selection of representative numbers of final vials of each exercise material;  after processing and dispensing of the exercise material into vials but before dispatch to participating laboratories. The number of vials chosen for homogeneity testing should be sufficient to assess possible variation in the exercise material. For each exercise material that has been dispensed an appropriate number of vials is selected randomly. ISO 17043 states: “Where appropriate, the provider or its subcontractors shall use a statistically random selection of a 36 S E C T I O N 5 representative number of samples from a batch of test material to assess the homogeneity of the material.” There is no defined number of vials required for homogeneity testing, though, as a guide, it is usual to select a minimum of 10% or 10 of the vials produced, whichever is the greater. However, the number of vials chosen for homogeneity testing should not exceed the capacity of a single test run to avoid interrun variation. It is important to ensure that the reactivity of the material has not changed in any of the vials selected and tested for homogeneity. An extensive homogeneity protocol must be undertaken and all records documented. For homogeneity testing, it is recommended that the first test method in the programme provider’s validated testing strategy for the appropriate marker is used. If a single vial does not produce the expected result, it may result in all vials containing the particular exercise material being removed from the exercise. An example of a protocol for homogeneity testing is included in Annex 5. 5.7 VERIFYING STABILITY It is necessary to validate the stability of materials in order to ensure that they are fit for use when they arrive in participating laboratories and no loss of material integrity has occurred. Temperature, time, biological material type, pathogen properties and other factors can contribute to loss of material integrity. The stability of materials can be tested by different mechanisms:  leaving vials unopened, at ambient temperature, for the length of time that exercise materials are expected to spend during distribution, followed by retesting to confirm reactivity;  conducting accelerated stability studies at different temperatures in the laboratory;  simulating real-time stability studies. Preparation and execution of a stability protocol will monitor and assess the rate of possible deterioration of the exercise materials. The stability of the exercise material should be monitored from the time of completion of EQA exercise material production through to, at least, the closing date of the exercise. The number of vials chosen for stability testing should be sufficient to allow testing to occur at regular intervals for the duration of the exercise. Regular monitoring will help pinpoint the time of deterioration, should it occur. It is recommended that stability continues to be monitored for a short period of time after the closing date of the exercise, in the event of any troubleshooting that may be required. Like homogeneity testing, it is recommended that the first test in the programme provider’s testing strategy for the appropriate marker to characterize the exercise material is used for stability testing. A stability protocol needs to be documented before the commencement of stability testing, taking into consideration the timeline of the exercise and factors that may influence the stability of the exercise material. Acceptance criteria must also be documented in the stability protocol outlining the actions taken if results show that the stability of an exercise material has deteriorated. In developing the acceptance criteria it is important to P L A N N I N G A N D O P E R A T I N G A N E Q A P R O G R A M M E F O R T T I . . . 37 allow for intrarun and interrun variation when analysing stability results. An example of a protocol for stability testing is included in Annex 6. Sending material to one or more distant participating laboratories that then return it for retesting is also sometimes used for stability testing. However, this only verifies the stability of the material while it is in transit, unless it is held at the participating laboratories for the duration of the exercise before it is returned. 5.8 PACKING AND DISPATCH Documentation appropriate to the specific EQA exercise should be included within the package. These include the instructions for handling the exercise materials and the forms for recording the results, if hard copy results forms are used. Although templates for this documentation will have been developed at the outset of the programme, it is important to proofread and check all documents before distribution to ensure that there are no contradictions, ambiguities or omissions in the information, and that the information pertains to the specific exercise being distributed. Accompanying documents should be sealed within a protective pouch and attached to the outside of the secondary package. If the EQA programme provider has decided to use electronic results forms, these should be emailed to the participants at the same time as the exercise materials are dispatched. A list of participating laboratories’ registration codes is helpful when packing exercises to ensure that no laboratory is missed. It is also important to have a protocol for packing, including checking that the correct combination of exercise materials and documents has been packed for each participating laboratory. Annex 7 contains an example of a record of exercise distributions and returned results that can be used as a packing checklist. If exercises are all distributed on a single day, it is sufficient to note the date and place a tick in the columns “Documentation packed”, “Materials packed” and “Exercise distributed” against each participating laboratory. The date of packing and distribution should be recorded for any participating laboratory to which exercises are sent on other dates. 5.9 COLLECTION OF AND DEADLINE FOR EQA RESULTS Participating laboratories are expected to submit the completed exercise results form to the EQA programme provider by the specified deadline date for the acceptance of results. Results received after this time should not be accepted, especially if stability validation processes do not extend beyond the deadline date. In order to encourage and remind participating laboratories, the EQA programme provider may contact participating laboratories a week before the deadline to remind participating laboratories to submit their results. Upon receipt by the EQA programme provider, the completed results forms should be date-stamped and filed in a manner that allows for easy retrieval. The EQA programme provider may choose to do a quick review of the results forms received to ensure the forms have been completed and that all information is legible and identify any gross errors. 38 S E C T I O N 5 5.10 COLLATION OF EQA RESULTS EQA exercise results from the participating laboratories should be collated in a manner that facilitates analysis. The approach for collating the results from an EQA exercise will depend upon how the data were collected and the type of data submitted. EQA exercise results should be collated in a single location that is a physically safe and confidential environment. Although manual-based collation of the results is possible, an electronic system is preferable to allow for ease of storage and analysis. It is essential that the EQA programme provider has a quality data management process in place. Manual-based systems will require higher levels of management to ensure that errors in transcription and data entry are minimized. The number of times data are handled should also be reduced to avoid errors. For both manual and electronic methods of results collation, secure data storage and maintenance of records (including adequate backup of electronica data) are required. The type of test results submitted by the participating laboratories (qualitative or quantitative) from one or more test methods needs to be considered in designing a system for collation and analysis. Whether each piece of supporting information (such as test method name, lot numbers, expiry dates, operator, test date, etc.) should also be included will depend on the way the data will be analysed. 5.11 ANALYSING EQA RESULTS In order to analyse the EQA exercise results, the reference result for each exercise material needs to be determined by the EQA programme provider. This reference result will usually be assigned based on characterization testing performed during the production of the EQA exercise material. However, occasionally, the reference result may be assigned based on a consensus of results from a group of laboratories. Ideally, this should occur rarely when an exercise material behaves in an unexpected manner and gives results that deviate from the characterization results. The reference results should be made clear to the participating laboratories. The complexity of the results analysis performed may depend on:  the maturity of the EQA programme and the technical knowledge of the EQA programme provider;  the aims of the EQA exercise;  the resources available to the EQA programme provider. Another important consideration is the time frame for providing feedback and reports to participating laboratories. Timely communication of laboratory performance in the EQA exercise may be more useful that an in-depth analysis that requires a prolonged time to complete. A simple approach to analysing EQA exercise results should highlight:  participating laboratories that reported results that differed from the reference results;  test methods that produced results that differed from the reference results. P L A N N I N G A N D O P E R A T I N G A N E Q A P R O G R A M M E F O R T T I . . . 39 Advanced approaches to analysing EQA exercise results may include:  investigating the performance of various test methods by grouping the data into subsets based on common test methods;  investigating the performance of the different reagent lots used by participating laboratories;  analyses of quantitative results using statistical tools. Each participating laboratory should receive an individual analysis of its performance for the exercise. The individual laboratory report should clearly highlight any results reported by the participating laboratory that differed from the reference results determined by the EQA programme provider. It is important to remember that only laboratory codes should be used when reporting or assessing the performance of participating laboratories, in order to maintain confidentiality. When analysing data sets or using statistical tools, it is important to be aware that making comparisons between small numbers of results may not be valid. 5.12 STATISTICAL ANALYSIS OF EQA EXERCISE RESULTS Quantitative results can be statistically analysed to determine whether any of the participants’ results for an exercise material differ significantly. To perform this type of analysis, data must be divided into like groups so that the data set analysed contains only results that were generated from the same test method (peer group). It is necessary to remove statistically outlying results that can skew the calculation of the average and standard deviation of a data set. Statistical methods for identifying outlying results include Grubbs’ test and Tukey’s filter.9 The summary statistics of the data set describing the mean, standard deviation and coefficient of variation can then be determined. This information provides the “target” values and allows a participating laboratory to compare its performance with that of the other participating laboratories using the same test method. EQA programme providers should consider that when the number of results in a data set is less than five the statistical profile generated may not provide an accurate representation of the results expected for the sample on that test method. Therefore, for small data sets, reporting a statistical profile is not useful or appropriate. Robust statistics are also commonly used for analysing EQA peer group results and are recommended by ISO 13528:2005, Statistical methods for use in proficiency testing by interlaboratory comparisons. 9 Barnett V, Lewis T. Outliers in statistical data, 3rd edition. Wiley; 1994. Tukey’s filter: http://www.statisticshowto.com/tukey-iqr-test/. 40 S E C T I O N 5 5.13 PREPARATION OF EQA REPORTS The outcomes of the analysis of results submitted for the exercise should be documented in a report that is made available to all of the participating laboratories. To maintain confidentiality of the participating laboratories, only identification codes should be used within the report. In this way information about the overall quality of testing among the participating laboratories can be communicated without breaching confidentiality. A short turnaround time for providing the EQA exercise report to the participating laboratories is a priority. An EQA exercise captures a snapshot of each participating laboratory’s performance at a particular point in time. Prompt feedback allows participating laboratories to investigate and take necessary corrective action on any identified deficiency whilst the problem is still relevant for the laboratory. Delays in feedback about performance may reduce the value of extensive analysis of the results performed. In situations where prompt feedback is unachievable for the EQA programme provider, an alternative procedure of sending out a preliminary report soon after the exercise closure, followed by the exercise report at a later date, may be acceptable to the participating laboratories. 5.14 PRELIMINARY REPORT The preliminary report is a summary of the composition of the materials in the EQA exercise. It does not contain any analyses of results, and hence can be prepared in advance. A preliminary report should contain:  the EQA exercise name, date and code;  characterization test results;  the reference results assigned to each exercise material. The information in the preliminary report allows participating laboratories to promptly review their performance in the exercise and implement corrective action if necessary. 5.15 FINAL REPORT The EQA exercise report should contain the following information:  the name and contact information for the EQA programme provider;  the name and code of the EQA exercise;  a description of the materials provided in the EQA exercise, including production methods and details of how the reference results were obtained;  the characterization test results for each exercise material;  the aims of the EQA exercise;  a description of the data analysis methods used;  the number of participating laboratories in the exercise;  individual assessment of participating laboratory results, highlighting those that differed from the reference results. In addition, the following information can enhance the value of the EQA programme: P L A N N I N G A N D O P E R A T I N G A N E Q A P R O G R A M M E F O R T T I . . . 41  a summary of the results reported for each exercise material by test method used;  systematic problems relating to a specific test method or reagent lot number used by participating laboratories;  advice to participating laboratories on how to troubleshoot laboratory errors;  general comments and discussion on the results submitted for the exercise. Care needs to be taken to make the EQA exercise report clear and informative. Developing a template that forms the basis of the report ensures consistency of the information delivered for each exercise and increases the efficiency of the report writing process. Comments and recommendations made by the EQA programme provider about the results submitted for an exercise should be non-judgemental, constructive and evidence based. The report of the EQA exercise can provide advice and suggestions for preventive action when reasons for error are able to be deduced. Depending on the type, frequency and severity of errors detected in EQA exercises, the programme provider may choose to offer additional action to assist a participating laboratory to rectify its testing processes (see section 6). Examples of a preliminary report and analyses that can be included in the final EQA exercise report are included in Annex 8. 5.16 CERTIFICATES OF PARTICIPATION Participation in EQA programmes is an important element of a laboratory’s quality management system. As such, laboratories may be required to demonstrate evidence of such participation and their performance. Although EQA reports and demonstration of corrective action following identified errors in EQA are the best evidence, many participating laboratories may also request a certificate of participation. The issue of an annual certificate of participation, detailing the number of exercises undertaken, can be a positive means of encouraging continued participation. Certificates of participation may be issued in a number of ways. For example, certificates may be issued after each EQA programme exercise or yearly. The EQA provider will need to define what constitutes “participation”. Certificates may be granted for participation in EQA, regardless of performance, or may be granted based on meeting minimum levels of performance. In either case, the EQA programme provider should predefine minimum levels of participation or performance and communicate these requirements to the participating laboratories. 42 6 Monitoring laboratory performance, feedback and education Performance monitoring involves setting standards of acceptable performance and identifying participating laboratories that fail to reach these standards. The EQA programme’s objective in identifying unsatisfactory performance is to offer advice and support to assist these laboratories in improving their performance. The need for monitoring of the performance of individual laboratories – and the initiation of appropriate corrective and preventive action in cases of persistent unsatisfactory performance – will be determined by the place of EQA within the existing national quality system. 6.1 SETTING STANDARDS OF ACCEPTABLE PERFORMANCE The first step in performance monitoring is to define standards of satisfactory, unsatisfactory and, possibly, “borderline” performance. The potential clinical significance of errors must be considered when defining standards of acceptable performance. When establishing an EQA programme, it is therefore advisable to operate the programme for a defined period, such as one year, with initial follow-up of errors as described below, but with no formal performance monitoring or scoring. During this time, information can be gathered on current levels of performance within each category of testing, such as rapid or test kit performance for TTI. This process will allow realistically achievable standards of acceptable performance to be set whilst ensuring that major errors, such as a false negative TTI result, are defined as unsatisfactory. For performance monitoring, there should be no differentiation between incorrect results due to technical or procedural errors (such as the incorrect transcription of results or the transposition of exercise materials), although they may be analysed and reported separately. An incorrect result in the blood transfusion laboratory or hospital blood bank can have the same serious consequences, regardless of the reason for the error. For this reason, it is advisable to base performance monitoring – and numerical scoring, if used – on interpretations made rather than on serological reactions recorded for each test. Along with incorrect results, non-return or late return of results also constitutes unsatisfactory performance. Performance standards should be agreed independently by the advisory committee, which includes representatives of participating laboratories M O N I T O R I N G L A B O R A T O R Y P E R F O R M A N C E , F E E D B A C K A N D . . . 43 and experts in the field. The advisory committee should also be responsible for regularly reviewing the definitions of unsatisfactory performance and making changes, where necessary, to reflect improvements in overall performance. 6.2 NUMERICAL SCORING SYSTEMS FOR PERFORMANCE MONITORING Scoring systems can be developed to allow the performance of individual laboratories to be monitored. While such scoring systems can objectively show what progress is being achieved, scoring can have the disadvantage of causing laboratories to collude or “cheat” for fear of obtaining an inadequate score. Such behaviour severely limits the value of EQA programme participation. Therefore it is important for the EQA programme provider to emphasize, to participating laboratory staff, their supervisors and their heads, the importance of non-punitive approaches to EQA performance. A scoring system using penalty points is easiest to weight for clinical significance and to use for the identification of unsatisfactory performance on a cumulative basis. Scoring can be “weighted” to reflect the potential clinical significance of errors made. The scoring system should be determined up front and communicated to participating laboratories as part of the EQA programme information manual. Cumulative scores can be used to identify persistent unsatisfactory performance as well as laboratories with “borderline” performance. Once the system is established, cumulative scores should be given with each exercise report. If this is not possible, cumulative scores can be provided for each laboratory in an annual summary to show trends in individual performance. Examples of numerical scoring systems for performance monitoring are included as Annex 9. 6.3 FOLLOW-UP OF UNSATISFACTORY PERFORMANCE Any follow-up actions by the EQA programme should comply with the procedures laid down by the advisory committee. While it is the role of an EQA programme to perform follow-up actions, the extent of these interventions should be documented and consistent with the resources available to the EQA programme provider. For example, an initial contact could be made by the EQA provider to determine possible causes of error and offer advice. If the EQA programme provider’s interventions yield no subsequent improvement in performance, a letter should be sent to the head of the laboratory to report the situation, formalize the advice that has been offered and suggest possible solutions. Procedures should be put in place to ensure that, once a laboratory becomes an unsatisfactory performer, its progress is then monitored until consistent satisfactory performance is achieved. Programme personnel should be non-judgemental and constructive regarding unsatisfactory performance. Any advice offered should be evidence based and in line with national standards or guidelines, where these exist. 44 S E C T I O N 6 Examples of severe errors include false negative results for any markers or multiple false positive results, failure to identify an intentional clerical error or sample mix-up. Options for ongoing assistance may include:  providing specific, long-term and recurrent advice on improvement opportunities;  providing additional EQA exercise material for troubleshooting;  providing hands-on laboratory training;  facilitating a supervisory visit or audit at the participating laboratory to identify deficiencies, including communication with the laboratory’s head. The programme provider’s ability to undertake these activities will depend on the resources allocated to them. The advisory committee should advocate strongly that these resources be provided, as the benefit of participation in EQA can be maximized only when these support activities are available. On an annual basis, a longitudinal review of performance of participating laboratories should be conducted. This will ensure that any participating laboratory with consistent problems from one EQA exercise to another is followed up adequately. To help monitor the performance of participating laboratories, the EQA programme provider may choose to keep a log of performance of participating laboratories in a logbook or spreadsheet for ease of review. 6.4 SELF-ASSESSMENT In the absence of any performance monitoring or follow-up by the EQA programme, a comparison of an individual laboratory’s results with those obtained by other laboratories is a useful means of highlighting the need for improvement. This process can often raise standards with no intervention from an external source. 6.5 EDUCATION The main purpose of an EQA programme is to improve performance and to provide assistance to address any problems detected. Education should therefore be inherent in all activities of an EQA programme. It can be provided to laboratories on an individual basis as well as to all participating laboratories and other relevant professionals. The programme has a particularly important educational role regarding errors made in EQA exercises by individual participating laboratories. When resources are available, EQA programme personnel can help laboratories identify the root causes of errors and make suggestions for changes in practice and procedures to prevent their recurrence. Errors in EQA exercises may be due to specific technical issues; however, apparently simple errors, such as transcription errors resulting in the recording of an incorrect TTI result, can be indicative of wider problems and deficiencies in a laboratory’s quality system. Education can be provided more widely in the form of reports on the overall performance of different techniques and technologies, which provide specific learning points on best practice. Once a programme is M O N I T O R I N G L A B O R A T O R Y P E R F O R M A N C E , F E E D B A C K A N D . . . 45 well established it may also be possible, with the help of the advisory committee, to organize an annual scientific meeting or a workshop for participating laboratories to address issues highlighted by the EQA exercises. The programme provider should, where possible, communicate information generated by the programme not only to participants but also to a wider audience, by making presentations at local, national and international meetings and through publications. EQA programme data can also be used as a basis for the writing and review of guidelines, making education accessible to all those working in the field of blood transfusion. 46 7 Monitoring and evaluating an EQA programme For an EQA programme to progress, it is important to monitor its development and evaluate its impact on a regular basis. This evaluation will also provide objective evidence in support of the programme’s continuation and be crucial for its sustainability. Evaluation should be undertaken at least once a year and a report produced. 7.1 INDICATORS Process and outcome indicators that could be used to assess the success of a programme are listed below. It should be recognized, however, that an improvement in relation to outcome indicators could be influenced by factors not directly related to participation in an EQA programme, such as the introduction of improved reagents or technology. Process and output indicators Examples of process and output indicators to be collected annually include:  frequency of advisory committee meetings and attendance;  proportion of participating laboratories;  proportion of laboratories returning results for each exercise – late and not at all;  number of laboratories registering for assessment of results on additional tests;  number of problems recorded in relation to the operation of the programme;  number of complaints received and resolved regarding the operation of the programme;  number of times exercise material fails to meet documented requirements;  positive feedback from participants;  troubleshooting and educational activities undertaken;  publications or presentations by the programme. Outcome indicators Examples of outcome indicators include:  proportion of satisfactory and unsatisfactory performance; M O N I T O R I N G A N D E V A L U A T I N G A N E Q A P R O G R A M M E 47  change in overall scores, if applicable;  trends in performance with the same material over several exercises;  improvement or changes in testing used by participating laboratories;  participating laboratories receiving accreditation. 7.2 IMPACT By analysing outcomes, the impacts that the programme has over a period of time can be determined. For example, the proportion of satisfactory versus unsatisfactory performance or the change in overall scores can infer the reduction in erroneous results on donor specimens obtained and therefore the minimization of transmission risk; the improvement in testing practices can be translated into savings in costs and in technologist time. When stakeholders and those providing the funding for the programme learn of these impacts, continued funding of the programme becomes simple to justify. 7.3 ANNUAL REPORT An annual report on the programme should be compiled and distributed to stakeholders, including ministry of health, advisory committee and other interested parties, such as participating laboratories. Its contents may include:  summary of the exercises distributed;  summary of overall performance, highlighting any trends;  summary of process indicators;  learning points from the exercises;  details of developments and challenges within the programme;  overall assessment of the impact of the programme;  human and financial resources, if appropriate and applicable. 48 Glossary This glossary has been prepared using definitions included in ISO 9000:2006, Quality management systems: fundamentals and vocabulary, or ISO 15189:2013, Medical laboratories: requirements for quality and competence. Where definitions were available in these standards, the document reference has been provided. Definitions in italics are intended to define the use of the relevant word or phrases within this document and how the terms relate to each other. Accreditation Procedure by which an authoritative body gives formal recognition that an organization is competent to carry out specific tasks (ISO 15189:2013). Audit Systematic, independent and documented process for obtaining evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled (ISO 9000:2006). Competence Demonstrated ability to apply knowledge and skills (ISO 9000:2006). Competency assessment Process to assess an individual’s ability to apply knowledge and skills. Documentation Written policies, instructions and records involved in providing a product or service. Effectiveness Extent to which planned activities are realized and planned results achieved (ISO 9000:2006). Exercise materials Materials that have been prepared from samples and that make up an EQA panel. External quality assessment (EQA) The external assessment of a laboratory’s performance using exercise materials of known, but undisclosed, content and comparison with the performance of other laboratories. External quality assessment programme A formal programme organized by a recognized institution. This can be a local programme or organized at national, regional or international level. Haemovigilance The monitoring, reporting and investigating of adverse incidents related to all blood transfusion activities. G L O S S A R Y 49 Internal quality control Procedures that verify the attainment of the intended quality of results (ISO 15189:2013). These may include procedures to monitor the day-to-day reproducibility of test results and detect major errors in the analytical process. Management system System to establish a quality policy and quality objectives and to achieve those objectives (ISO 9000:2006). Marker Specific characteristics of exercise materials included in the EQA programme, e.g. HIV antibody, HIV antigen, Treponema antibody. Panel A set of EQA exercise materials. Procedure Specified way to carry out an activity or a process (ISO 9000:2006). Process Set of interrelated or interacting activities that transform inputs into outputs (ISO 9000:2006). Quality The degree to which a set of inherent characteristics fulfils requirements (ISO 9000:2006). Quality management Coordinated activities to direct and control an organization with regard to quality (ISO 9000:2006). Sample A specimen, preferably of large volume, that has been processed, tested, and stored in a sample bank for potential use as exercise material. Specimen Discrete portion of a body fluid, breath, hair or tissue taken for examination, study or analysis of one or more quantities or properties assumed to apply for the whole (ISO 15189:2013). Standard operating procedure Specified way to carry out an activity or a process that is documented, implemented and maintained (ISO 15189:2013). Test Determination of one or more characteristics according to a procedure (ISO 9000:2006). Validation Confirmation through the provision of objective evidence that the requirements for a specific intended use or application have been fulfilled (ISO 9000:2006). Annexes The following annexes are provided for information and as examples on which prospective EQA programme providers may wish to base their documentation and other aspects of the design of their programme, with appropriate local modifications. 1. Preliminary questionnaire for potential participating laboratories 2. EQA registration form 3. Exercise instruction sheet 4. Exercise results form 5. Protocol for homogeneity testing of exercise material 6. Protocol for stability testing of exercise material 7. Record of exercise distributions and returned results 8. Exercise analysis and report 9. Numerical scoring systems 52 Annex 1 Preliminary questionnaire for participating laboratories External quality assessment programme for TTI screening of donated blood Please complete this questionnaire regarding transfusion-transmissible infections screening and general quality measures in your laboratory. Part 1. Contact details Institution name: Contact name: Department: Address: Telephone: Facsimile: Email address: Part 2. Laboratory information 1. Number of staff: 2. Number of specimens processed per year from: Blood donors Others (please specify) 3. Please indicate the TTI screening performed in your laboratory and the test method(s) used Mandatory screening* HIV HCV HBV Syphilis Chagas HTLV I/II Malaria The TTI screened in your laboratory        The TTI for which your laboratory would like an EQA programme        * Screening as mandated by the country A N N E X 1 53 Markers Name of test kits used in your laboratory Name of test kit’s manufacturer Instrument Volume required (mL) include repeat tests and dead volume Test methods used 4. Are independent (not test kit control) internal quality control (IQC) samples included in each test run?  Yes  No If yes, is the performance of these IQCs recorded and monitored over time?  Yes  No 5. Does your laboratory have a microcentrifuge?  Yes  No If yes, what is the minimum and maximum rpm at which it operates? 6. Does your laboratory have a refrigerator?  Yes  No Part 3. EQA scheme preferences How many materials per panel?  1–3  5  10 How many exercises per year?  1  2  3 General comments: 54 Annex 2 EQA registration form Institution name: Contact name: Department: Postal address: Shipping address: Telephone: Facsimile: Email address: Additional contact for receiving report if required Email address: Please indicate the EQA programmes in which your laboratory would like to enrol. Each exercise includes five exercise materials. Participation in two exercises each year is considered the minimum acceptable. Exercise number HIV HCV HBV Syphilis Chagas HTLV I/II Malaria 1        2        3        55 Annex 3 Exercise instruction sheet Intended use This is a coded panel of exercise materials each with known reactivity for: [insert markers included in the panel for assessment]. It is intended to be used for the assessment of the performance of laboratories undertaking routine TTI screening of blood donations. Materials provided  X (insert number) vials of serum exercise materials of Y [insert volume] labelled: 1A, 1B, …  Result sheets Instructions for storage, handling and testing of exercise materials  Vortex, then centrifuge all exercise materials prior to testing.  Process the exercise materials alongside routine donor specimens and in the same way as they would usually be processed by your laboratory.  Warning: The exercise materials are potentially infectious and should be handled using universal safety precautions.  Materials are to be stored at 2–8°C for the duration of the exercise. Instructions for testing of exercise materials  Test the exercise materials in the same way as routine donor specimens would normally be tested, using the testing strategy in use in your laboratory. Instructions for completing the results form  Please tick the relevant box where you have been given a choice of response.  Report only the results of one test kit on each page. Photocopy the relevant page(s) for additional results.  Definitions of abbreviations used in the form: (example) — R: Reactive — N: Negative — INC: Inconclusive Instructions for returning the results  Ensure the return of the results before closing date. 56 Annex 4 Exercise results form Exercise identification code: 01/04 (example) Laboratory registration code: Contact name: Institution name: Telephone number: Email: Date on which your laboratory received the panel: Were the materials received in good condition?  Yes  No Comments: (If panels were received in an unsatisfactory condition, replacement panels can be obtained by contacting the EQA programme provider on the details listed below). The closing date for exercise 01/04 is DD/MM/YYYY Please return completed results forms to [insert EQA provider’s details]: EQA programme provider: EQA contact name: Address: Telephone: Facsimile: Email: A N N E X 4 57 EXERCISE RESULTS FORM: EIA Exercise 01/04 Laboratory registration code: Test kit name: 1st run Operator: Date of testing: Kit lot number: Kit expiry date: 2nd run Operator: Date of testing: Kit lot number: Kit expiry date: Supervisor: Results Exercise material ID S/Co ratio (1st run) S/Co ratios (2nd run) Test kit interpretation OD (A) Cut- off (B) S/Co (A÷B) OD (A) Cut- off (B) S/Co (A÷B) Rep 1 Rep 2 Rep 1 Rep 2 1A  R  N  INC 1B  R  N  INC ...  R  N  INC ...  R  N  INC 1X  R  N  INC Comments: Name of operator reporting results: 58 A N N E X 4 EXERCISE RESULTS FORM: RAPID TEST Programme name / ID: Participant ID: Test kit lot number: Test kit expiry date: Operator initials: Exercise material ID Test date First reader Second reader Final result interpretationc Reader IDa Ab bar / spotb Ag bar / spotb Control bar / spotb Reader IDc Ab bar / spotb Ag bar / spotb Control bar / spotb a Initials. b Neg, Pos, Not Applicable (N/A). c Negative, Reactive, Invalid. 59 Annex 5 Protocol for homogeneity testing of exercise material  Example: Panel composition of exercise panel ID: 01/04 contains 5 exercise materials labelled 1A, 1B, 1C, 1D and 1E.  80 vials of each exercise material were produced and aliquoted during production.  10 representative vials of each EQA exercise material (refer section) are selected for homogeneity testing.  Using a random number generator, record the 10 vial numbers selected for homogeneity testing (e.g. vials 15, 25, 31, 47, 58, 66, 70, 80, 12, 22).  The same vial numbers are to be set aside for each exercise material.  The selected vials need to be renumbered with new homogeneity codes to ensure traceability during testing (e.g. 1A:H1, 1A:H2 ……… 1A:H10, etc.)  Store vials for homogeneity testing at 2–8°C until the testing is performed.  Test each vial once on the appropriate test kit in the same test run.  Any exercise material found to have a result that is different from the reference result must be retested in duplicate. The final test interpretation for this exercise material will be based on the consensus of the three test results. Record results in the appropriate form (see following table).  Before disposal, store the homogeneity vials at 2–8°C until homogeneity results are reviewed and accepted by the EQA programme provider.  Acceptance criteria: An exercise material shall be accepted for inclusion in a panel if all of the test result interpretations for each vial agree with the reference result. 60 A N N E X 5 EXAMPLE: HOMOGENEITY TESTING RESULTS FOR EXERCISE PANEL ID: 01/04 Exercise material: 1A 1B 1C 1D 1E Reference: result Reactive Negative Negative Reactive Reactive H1 Reactive Negative Negative Reactive Reactive H2 Reactive Negative Negative Reactive Reactive H3 Reactive Negative Negative Reactive Reactive H4 Reactive Negative Negative Reactive Reactive H5 Reactive Negative Negative Negative* Reactive H6 Reactive Negative Negative Reactive Reactive H7 Reactive Negative Negative Reactive Reactive H8 Reactive Negative Negative Reactive Reactive Acceptance: Pass Pass Pass Fail* Pass * Repeat testing required in duplicate. The final test interpretation for this exercise material will be based on the consensus of the three test results. 61 Annex 6 Protocol for stability testing of exercise material  Example: Panel composition of exercise panel 01/04 contains 5 exercise materials labelled 1A, 1B, 1C, 1D and 1E.  80 vials of each exercise material were produced and aliquoted during production, which included 6 vials of each exercise material to be selected for stability testing.  The selected vials need to be renumbered with new stability codes to ensure traceability during testing (e.g. 1A:S1, 1A:S2, 1A:S3, 1A:S4, 1A:S5 and 1A:S6).  Identify the time and temperature conditions that the exercise material will be exposed to for the duration of the exercise. EXAMPLE: ACTIVITY AND SCHEDULE FOR EXERCISE PANEL ID: EXERCISE MATERIAL 1A 01/04 Activity Schedule Exercise material Storage temperature conditions Post-production Day 0 2–8°C Start of dispatch Day 4 S1 37°C End of dispatch Day 11 S2 37°C Opening date of exercise Day 12 S3 2–8°C Middle date of exercise Day 25 S4 2–8°C Closing date of exercise Day 32 S5 2–8°C 7-day storage after closing date Day 39 S6 2–8°C  Store stability vials at 2–8°C for 4 days until exercise panels are dispatched to the participating laboratories. Remove stability vial 1A:S1 on day 4, test on the appropriate test kit for the analyte.  Move the remaining 5 stability vials to 37°C ± 1°C and store for 7 days.  Remove stability vial 1A:S2 on day 11, test on the appropriate test kit for the marker.  Move the remaining 4 stability vials and store at 2–8°C. Test the following vials on the appropriate test kit for the analyte as follows: — 1A:S3 on day 18 — 1A:S4 on day 25 — 1A:S5 on day 32 — 1A:S6 on day 39.  Any exercise material found to have a result that is different from the reference result must be retested in duplicate. The final test interpretation for this exercise material will be based on the consensus of the three test results. Record results in the appropriate form (see below). 62 A N N E X 6  Acceptance criteria: Criteria for suitable stability should be based on the effect that instability will have on the uncertainty of the participant’s result, and thereby on the evaluation of the acceptability of a participant’s results. EXAMPLE: STABILITY TESTING RESULTS FOR EXERCISE PANEL ID: 01/04 Exercise material: 1A 1B 1C 1D 1E Reference: result Reactive Negative Negative Reactive Reactive S1 Reactive Negative Negative Reactive Reactive S2 Reactive Negative Negative Reactive Reactive S3 Reactive Negative Negative Reactive Reactive S4 Reactive Negative Negative Reactive Negative* S5 Reactive Negative Negative Reactive Negative* S6 Reactive Negative Negative Reactive Negative* Acceptance: Stable Stable Stable Stable Unstable * Repeat testing required in duplicate. The final test interpretation for this exercise material will be based on the consensus of the three test results. 63 Annex 7 Record of exercise distributions and returned results PANEL ID NUMBER: Laboratory code Documentation packed Materials packed Exercise distributed Results received Comment 0001 0002 0003 0004 0005 0006 0007 0008 0009 0010 0011 0012 0013 0014 0015 0016 0017 0018 0019 0020 0021 0022 0023 0024 64 Annex 8 Exercise analysis and report PRELIMINARY REPORT Material ID* Sample type Comments Anti-HIV-1 status p24 reference result 1 Plasma Negative Negative 2 Pooled plasma Positive Negative 3 Pooled plasma Positive Negative 4 Pooled plasma Negative Negative 5 Pooled plasma Positive Negative 6 Plasma Negative Negative 7 HIV-1 culture supernatant diluted in negative human plasma The sample contains ~5000 pg/mL of subtype B cell culture supernatant Negative Positive 8 Plasma Negative Negative 9 Pooled plasma Positive Negative 10 Plasma Negative Negative * Identification. A N N E X 8 65 CHARACTERIZATION OF THE SAMPLES THAT COMPRISED ANTI-HIV EQA PANEL ID Material ID Murex HIV-1.2.O Ag/Ab EIA (S/Co*) Bio-Rad Genetic Systems HIV- 1 Ag** EIA (S/Co) Bio-Rad Genetic Systems HIV-1 Ag confirmatory HIV-1 western blot Anti HIV-1 status p24 reference result p18 p24 p31 p34 gp41 p53 p68 Test result interpretation 1 0.41 0.20 Not tested Not tested Not applicable Negative Negative 2 14.96 0.24 Not tested – ++ – + ++ ++ +++ Positive Positive Negative 3 15.21 0.21 Not tested – +++ – ++ +++ +++ +++ Positive Positive Negative 4 0.48 0.25 Not tested Not tested Not applicable Negative Negative 5 18.82 0.24 Not tested +++ +++ ++ ++ +++ +++ +++ Positive Positive Negative 6 0.39 0.25 Not tested Not tested Not applicable Negative Negative 7 0.31 40.66 37.83 Not tested Not applicable Negative Positive 8 0.37 0.26 Not tested Not tested Not applicable Negative Negative 9 18.57 0.25 Not tested ++ +++ ++ ++ +++ +++ +++ Positive Positive Negative 10 0.41 0.20 Not tested Not tested Not applicable Negative Negative * Sample: cut-off ratio, where ≥1 is reactive. ** Antigen. 66 A N N E X 8 ANALYSES FOR INCLUSION IN FINAL EXERCISE REPORT Percentage of false negative and false positive results by marker False positive % False negative % Syphilis 0 0 0 0 TND = 100 TPD = 28 HIV 10 9.80 0 0 TND = 102 TPD = 68 Anti-HTLV-I/II 0 0 0 0 TND = 56 TPD = 19 HCV 0 0 0 0 TND = 85 TPD = 26 HBsAg 0 0 2 7.1 TND = 90 TPD = 28 Total 10 2.2 2 1.1 TND = 448 TPD = 175 TND = Total of determinations performed in negative samples. TPD = Total of determinations performed in positive samples. Participants’ performance by marker Participant ID HIV HBsAg Syphilis HCV anti-HTLV-I/II 1 A A A A A 2 A A A A – 3 A A A A A 4 A A A A A 5 A A A A A 6 A A A A A 7 A A A A A 8 A A A A A 9 A A A A – 10 A A A A – 11 B2 A A A A 12 B2 A A A A 13 B2 A A A – 14 A C A A – A = 100% of concordance. B1 = False positive result was reported (≤ 5% of the total of individual participant’s determinations). B2 = False positive result was reported (> 5% of the total of individual participant’s determinations). C = False negative result. – = Not performed A N N E X 8 67 False positive and false negative results (%) reported for each exercise material 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7,69 7,14 4,35% Material ID ANALYSIS BY TEST KIT Example table below shows the number of false results reported for each syphilis test kit used by the participants. Similar tables can be created for the other markers. Test kits FPR % TND FNR % TPD Architect syphilis TP 0 0 30 0 0 9 Murex ICE syphilis 0 0 15 0 0 3 Macrovue RPR card 0 0 10 0 0 2 Trepanostika TP recombinante 0 0 10 0 0 5 Total 0 0 65 0 0 19 TND = Total of determinations performed in negative samples. TPD = Total of determinations performed in positive samples. FPR = False positive results. FNR = False negative results. % FP % FN 68 Annex 9 Numerical scoring systems SIMPLEST SCORING METHOD EVALUATES ONLY THE FINAL STATUS OF EACH MATERIAL WITH TOTAL SCORE OF 100% EQA panel ID Year Score Expected results Positive Negative Negative Positive Positive Material ID 1 2 3 4 5 Participant results Negative Positive Negative Negative Positive 80% SCORING METHOD FOR BOTH TEST RESULT AND FINAL INTERPRETATION EQA panel ID Year Participant results Material ID (expected results) Test kit 1 Test kit 2 Test kit 3 Final status Score 1 (Negative) Non-reactive Not done Not done Negative 2 of 2* or 20 2 (Positive) Reactive Reactive Non-reactive Positive 3 of 4 or 15 3 (Positive) Reactive Reactive Reactive Positive 4 of 4 or 20 4 (Negative) Reactive Non-reactive Non-reactive Inconclusive 2 of 4 or 10 5 (Positive) Reactive Reactive Reactive Positive 4 of 4 or 20 Total score 85% Maximum score = 100 with 20 points allocated to each exercise material. Within each exercise material there are up to four answers required. * Maximum score allocated: both possible answers correct (test kits 2 and 3 did not require answers for material 1). A N N E X 9 69 SCORING METHOD FOR TEST RESULTS, FINAL INTERPRETATION AND FOLLOWING ALGORITHM EQA panel ID Year Participant results Score Material ID (expected results) Test kit 1 Test kit2 Test kit3 Final status Test results (80%) Test algorithm (20%) 1 (Negative) Non-reactive Non-reactive Non-reactive Negative 16/16 0/4* 2 (Positive) Reactive Reactive Non-reactive Positive 12/16 4/4 3 (Positive) Reactive Reactive Reactive Positive 16/16 4/4 4 (Negative) Reactive Non-reactive Non-reactive Inconclusive 8/16 4/4 5 (Positive) Reactive Reactive Reactive Positive 16/16 4/4 Total score 84% Maximum score = 100 points with 20 points allocated to each exercise material. Within each exercise material there are up to four answers required worth 4 points each and 4 points awarded if the algorithm was followed. * No point awarded for following the algorithm because participant continued to test in test kits 2 and 3 despite obtaining a negative result in test kit 1 for material 1. Confidential performance evaluation by marker: External quality assessment scheme – panel ID: Participant ID: Syphilis HIV HTLV HCV HBsAg A A A A A Qualification criteria: A 100% correct results, no false positive and no false negative results. B1 False positive result was reported (≤ 5% of the total of determinations performed by the participant). B2 False positive result was reported (> 5% of the total of determinations performed by the participant). C False negative result was reported.

Implementation Guide Establishing External Quality Assessment Programmes for Screening of Donated Blood for Transfusion-Transmissible Infections Establishing External Quality Assessment Programmes for Screening of Donated Blood for Transfusion-Transmissible Infections Implementation Guide WHO Library Cataloguing-in-Publication Data Establishing external quality assessment programmes for screening of donated blood for transfusion-transmissible infections: implementation guide. 1.Blood Transfusion - adverse effects. 2.Blood Transfusion - standards. 3.Disease Transmission, Infectious - prevention and control. 4.Donor Selection. I.World Health Organization. ISBN 978 92 4 151583 2 This publication was originally published under ISBN 978 92 4 151043 1 (NLM classification: WB 356) © World Health Organization 2016 All rights reserved. Publications of the World Health Organization are available on the WHO website (http://www. who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (http://www.who.int/about/licensing/ copyright_form/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. 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Contents ACKNOWLEDGEMENTS ABBREVIATIONS INTRODUCTION 1 1 EXTERNAL QUALITY ASSESSMENT 3 1.1 EQA as part of a quality system in the screening of donated blood for TTI 3 1.2 Assessment 4 1.3 External quality assessment 5 1.4 Objectives and benefits of EQA 5 1.5 EQA programmes 6 2 ESTABLISHING EQA PROGRAMMES FOR TTI SCREENING 8 2.1 Organizing institution 8 2.2 Advisory committee 10 2.3 Technical and administrative support 11 2.4 Information management system 12 2.5 Finances 13 2.6 Quality system of the EQA programme 14 2.7 Participating laboratories 15 2.8 Pilot study 16 2.9 Practical steps in establishing an EQA programme 16 3 PARTICIPATING LABORATORIES 18 3.1 EQA programme information manual 18 3.2 Rules of participation 19 3.3 Registration 20 4. PRACTICAL CONSIDERATIONS IN ESTABLISHING AN EQA PROGRAMME 22 4.1 Scope 22 4.2 EQA programme exercise format 22 4.3 EQA programme objectives 23 4.4 Sources of exercise material 23 4.5 Establishing a sample bank 24 4.6 Processing candidate exercise material 25 4.7 Exercise documentation 29 4.8 Logistics 31 5. PLANNING AND OPERATING AN EQA PROGRAMME FOR TTI TESTING 32 5.1 Developing an annual EQA programme plan 32 5.2 Developing the plan for a specific EQA exercise 33 5.3 Selection of material for EQA exercises 33 5.4 Preparation of exercise materials 34 5.5 Dispensing exercise material 34 5.6 Verifying homogeneity and stability 35 5.7 Verifying stability 36 5.8 Packing and dispatch 37 5.9 Collection of and deadline for EQA results 37 5.10 Collation of EQA results 38 5.11 Analysing EQA results 38 5.12 Statistical analysis of EQA exercise results 39 5.13 Preparation of EQA reports 40 5.14 Preliminary report 40 5.15 Final report 40 5.16 Certificates of participation 41 6. MONITORING LABORATORY PERFORMANCE, FEEDBACK AND EDUCATION 42 6.1 Setting standards of acceptable performance 42 6.2 Numerical scoring systems for performance monitoring 43 6.3 Follow-up of unsatisfactory performance 43 6.4 Self-assessment 44 6.5 Education 44 7. MONITORING AND EVALUATING AN EQA PROGRAMME 46 7.1 Indicators 46 7.2 Impact 47 7.3 Annual report 47 GLOSSARY 48 ANNEXES 51 1. Preliminary questionnaire for potential participating laboratories 52 2. EQA registration form 54 3. Exercise instruction sheet 55 4. Exercise results form 56 5. Protocol for homogeneity testing of exercise material 59 6. Protocol for stability testing of exercise material 61 7. Record of exercise distributions and returned results 63 8. Exercise analysis and report 64 9. Numerical scoring systems 68 Acknowledgements The Blood Transfusion Safety Programme in the WHO Department of Service Delivery and Safety wishes to express its thanks to the experts in external quality assessment screening for transfusion-transmitted infections who contributed to the development of these guidelines. Authors Ms Susan Best and colleagues National Serology Reference Laboratory Melbourne, Australia The authors also acknowledge the following individuals who prepared the WHO publication External quality assessment of transfusion laboratory practice: guidelines on establishing an EQA scheme in blood group serology (WHO/ EHT/04.09), to which the present publication is a companion. Ms Jenny White, Deputy Scheme Manager, NEQAS for Blood Transfusion Laboratory Practice Watford, United Kingdom Mr Robin Knight, Red Cell Immunohematology Service Development Manager, National Blood Service, North London Blood Centre, United Kingdom Editorial team and contributors Dr Wilai Chalermchan, Senior Laboratory Advisor (contractor), Thailand MOPH – U.S. CDC Collaboration (TUC) Dr Marcia Mitiko Otani, Chefe Depto Controle de Qualidade Serologia, Fundação Pró-Sangue Hemocentro de São Paulo, Brazil Dr Neelam Dhingra, Coordinator, Patient Safety and Quality Improvement, Service Delivery and Safety, WHO Dr Noryati Abu Amin, Medical Officer, Blood & Transfusion Safety, Service Organization and Clinical Interventions Unit, Service Delivery and Safety Department, WHO Mr Junping Yu, Technical Officer, Blood & Transfusion Safety, Service Organization and Clinical Interventions Unit, Service Delivery and Safety Department, WHO Critical readers Dr Alan Kitchen, Head of National Transfusion Microbiology Reference Laboratory, NHS Blood and Transplant, United Kingdom Dr Jane Carter, Amref Health Africa, Wilson Airport, Langata Road, Nairobi, Kenya Dr Vengetassen (Ravi) Reddy, Chief Operations Officer, South African National Blood Service Dr Vivienne James, Northern Sydney Central Coast Health, Australia Dr Xun Wang, Head of Transfusion-Transmitted Disease Laboratory, Shanghai Blood Centre, China Dr Panadda Silva, Director/Expert at Department of Medical Sciences, Ministry of Health, Thailand The publication was coordinated by Dr Noryati Abu Amin and Mr Junping Yu. Overall guidance was provided by the Coordinator, Patient Safety and Quality Improvement Unit, Dr Neelam Dhingra and the Coordinator of Service Organization and Clinical Interventions Unit, Dr Hernan Montenegro. Development of this publication was supported by Cooperative Agreement Number GH001180 from the United States Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of CDC. 1Introduction External quality assessment (EQA) is an important component of quality systems for blood transfusion services. EQA is the external assessment of a laboratory’s overall performance in testing exercise material of known, but undisclosed, content and comparison with the performance of other laboratories that have tested the same material. In laboratories that screen donated blood for transfusion-transmitted infections (TTI), participation in EQA helps to monitor and raise standards of performance. Information generated by EQA provides an opportunity for continual quality improvement through the identification of laboratory errors and the implementation of measures to prevent their recurrence. Thus EQA plays a vital role in making blood safer. The World Health Organization (WHO) plays an advocacy role in promoting the establishment of national EQA programmes and encourages participation by TTI screening laboratories in these programmes. National health authorities are urged to recognize the importance of EQA and support the implementation of these programmes throughout a country’s TTI screening network. Professional bodies are encouraged to endorse and support the establishment of EQA programmes. Establishing external quality assessment programmes for screening of donated blood for transfusion-transmissible infections: implementation guide aims to support WHO Member States in establishing and operating EQA programmes for screening donated blood for TTI. The guide has been designed for use by national health authorities and EQA organizing institutions in the development of EQA programmes that can be implemented at national, state, provincial and district levels. It will also give participating laboratories an insight into the organization of EQA programmes for TTI screening and an understanding of the benefits of participation. This guide is intended to be a companion to the WHO publication External quality assessment of transfusion laboratory practice: guidelines on establishing an EQA scheme in blood group serology (WHO/EHT/04.09). Hence, much of the present guide mirrors the information included in the earlier publication. This is because general principles of external quality assessment are the same irrespective of discipline. The scope of the guidance described here includes mandatory serology screening of all blood donation for HIV, hepatitis B and C, and syphilis. 2I N T R O D U C T I O N It may also be used to guide implementation of EQA for other agents for which mandatory screening is required in a particular country or region.1 Although screening for HIV, hepatitis B and hepatitis C using nucleic acid testing is undertaken in some Member States, establishing an EQA programme for nucleic acid testing is outside the scope of this guidance, as it would require different approaches to sample acquisition, characterization and analysis, additional infrastructure and stringent logistical conditions. This guide is designed to support the establishment of EQA programmes by organizing institutions that are in different stages of development. A phased approach should be considered if it is not possible initially to implement all the elements described here. The establishment of even a basic, small programme can have a significant impact in raising standards. When establishing an EQA programme in TTI screening, assessment of the most clinically important tests should be included first; the range of tests assessed can then be expanded as the programme is further developed. The guide describes the principles for establishing and operating an EQA programme for TTI screening. EQA programmes should be organized in accordance with these principles, although due consideration should also be given to regulatory and quality system mechanisms that may exist within a country for laboratories conducting TTI screening. 1 Screening donated blood for transfusion-transmissible infections: recommendations. Geneva: World Health Organization; 2010. 31 External quality assessment The transfusion of safe, compatible blood and blood products involves a number of processes. There is a risk of error in each process from the selection of blood donors, the collection, processing and testing of donated blood, the testing of specimens from potential transfusion recipients, and the issue of compatible blood and its administration to the recipient. The laboratory plays a key role in this transfusion chain and quality system failures in screening donated blood for TTI can have serious implications for the recipients of blood and blood products. Haemovigilance programmes, such as the Serious Hazards of Transfusion (SHOT) programme in the United Kingdom, have shown that laboratory errors can lead to major morbidity and mortality in transfusion recipients. Errors in the laboratory may be due to a number of deficiencies, including:  inadequate procedures for identification of donor specimens  incorrect storage or use of inappropriate reagents  inadequate equipment maintenance  poor testing practices  inaccuracies in recording or transcription  inadequate procurement practices  inadequate staff training. Errors often result from a combination of factors, with the original error being compounded by inadequate checking procedures in the laboratory. The aim of screening donated blood for TTI is to provide safe blood and blood products for transfusion. The implementation of a quality system in the TTI screening laboratory seeks to ensure this aim is achieved by minimizing errors. Accurate screening for TTI is essential for providing safe blood and blood products. Along with the performance of a test, it is equally important that the results are transcribed, collated and interpreted correctly so that safe blood products are issued for transfusion. 1.1 EQA AS PART OF A QUALITY SYSTEM IN THE SCREENING OF DONATED BLOOD FOR TTI External quality assessment forms an integral part of the monitoring of the overall quality system in a laboratory in which TTI screening is performed. National authorities should determine the standards with 4S E C T I O N 1 which quality systems in laboratories should comply. These standards can be developed nationally based on international standards or relevant international standards can be applied. The key elements of a quality system are:  organizational management, including: — quality policy and plan — clear organizational structure — designated individual(s) with responsibility for establishing and managing the quality system — job descriptions for all staff;  accurate and complete documentation, including standard operating procedures, and a functioning document control system;  training, mentoring and continued professional development of staff;  equipment validation, maintenance and calibration;  validation of reagents, consumables, techniques and, where applicable, software;  assessment, including: — internal quality control — internal and external audit — external quality assessment. 1.2 ASSESSMENT Continuous quality improvement requires ongoing monitoring and review of the effectiveness of all elements of the quality system, using both internal and external mechanisms, to ensure that the defined quality standards are being met consistently. Internal assessment of the quality system in the laboratory includes:  full validation of all activities, processes, procedures, equipment, reagents and software prior to their introduction and use;  regular monitoring of all critical activities where continuous measurement of the outcomes is both possible and appropriate.  use of specific control measures, such as quality control samples, to monitor the performance of critical activities;  staff competency assessment;  development of an internal audit system, using relevant standards or other regulatory and licensing requirements;  development of a system for the reporting, investigation and analysis of errors, with effective corrective and preventive action. External assessment of the quality system in the laboratory includes:  participation in an appropriate EQA programme;  external audit by a recognized independent body. Documentation: Written policies, instructions and records involved in providing a product or service. Standard operating procedure: Specified way to carry out an activity or a process that is documented, implemented and maintained – ISO 9000:2006 Internal quality control: Procedures that verify the attainment of the intended quality of results – ISO 15189:2013. These may include procedures to monitor the day-to-day reproducibility of test results and detect major errors in the analytical process. Audit: Systematic, independent and documented process for obtaining evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled – ISO 9000:2006. Effectiveness: Measure of the extent to which planned activities are realized and planned results achieved – ISO 9000:2006. Validation: Confirmation and provision of objective evidence that the requirements for a specific intended use or application have been fulfilled – ISO 9000:2006. Competency assessment: Process to assess an individual’s ability to apply knowledge and skills. E X T E R N A L Q U A L I T Y A S S E S S M E N T 5 1.3 EXTERNAL QUALITY ASSESSMENT Participation in EQA programmes is one of several effective mechanisms for identifying deficiencies or improvement opportunities within a laboratory’s processes and periodically provides an objective view of performance relative to that of other laboratories. Other EQA mechanisms include monitoring through supervisory visits or audits or sample exchange programmes. In the latter, materials are exchanged between laboratories and tested in a coded fashion. The results are analysed to determine whether all laboratories participating in the sample exchange achieve the same results. Participation in EQA involves testing sets of exercise materials of known, but undisclosed, content that are sent to participating laboratories by the EQA programme provider. Each participating laboratory receives an identical set of exercise materials, which should be processed in the same way as routine blood donor specimens to ensure that the laboratory’s performance in EQA accurately reflects its usual performance. Once the EQA exercise materials are tested, participating laboratories send the test results obtained back to the EQA programme provider. Following the collation and analysis of results, each laboratory receives feedback on its own results, together with the anonymized results for all other participating laboratories and the reference results, which enables it to compare its performance with that of other participants. The assessment of performance through EQA enables a laboratory to determine either that their systems are operating effectively or that deficiencies exist that require correction. As a result, corrective and preventive measures can be implemented as necessary. Thus, information generated by the programme helps to improve the overall quality of the laboratory and the safety of the blood and blood products it issues for transfusion. Even if a complete quality system is not in place, EQA can still be introduced as part of a process of continual quality improvement. 1.4 OBJECTIVES AND BENEFITS OF EQA The overall objective of EQA is to measure, maintain and improve as necessary the standards of performance in laboratories. Support for the national adoption of EQA can be achieved by raising awareness of the need for improvement, demonstrating the benefits of best practice, and providing information, education and support for improvement. Benefits to participating laboratories The benefits of EQA to participating laboratories include:  identification of opportunities for improvement relating to laboratory processes;  comparison of a laboratory’s own performance with that of other participating laboratories;  comparison of performance between different testing systems;  provision of information and education to improve performance;  encouragement of best practice; 6S E C T I O N 1  opportunities to enhance the credibility of the laboratory and increase public confidence;  access to a network of laboratories for the exchange of information. Benefits to health and regulatory authorities The benefits of EQA to health and regulatory authorities include:  establishment of a network of blood transfusion laboratories with a known standard of performance;  training and education of laboratory staff;  provision of useful information to assist in: — setting standards — reviewing testing strategies — postmarket surveillance of test kits, reagents, instruments — using resources effectively — improving public confidence in the blood transfusion service — supporting systems of accreditation. EQA is most effective in raising standards when the need for quality is recognized. This must be accompanied by commitment from senior management to support the changes needed to improve performance. Participation in EQA can be an effective means of driving quality forward in situations where quality systems are not in place. EQA results can reveal poor performance and assist in identifying the need for standards, guidelines, education and training, and the resources required to support them. 1.5 EQA PROGRAMMES EQA should be organized as a formal and structured programme to ensure effective planning and organization. This will ensure the uniform provision of exercise materials for testing and a standardized approach to both the analysis and reporting of results and the monitoring of performance of participating laboratories. If it is possible for the EQA organizing institution to be accredited to or comply with the principles of ISO/IEC 17043:2010, Conformity assessment: general requirements for proficiency testing, this will assist in achieving the standardization required. EQA should be made available to all laboratories in which TTI screening is performed, regardless of their size, workload or the complexity of the tests performed. Depending on the policy and regulatory systems in place, laboratories could participate in EQA on either a voluntary or a mandatory basis. Where participation is voluntary, laboratories should be actively encouraged to register for EQA all tests that they routinely perform. Figure 1 shows one model for a network of EQA programmes developed at international, regional and national levels. At each level, the programme provides the EQA exercise materials, advice and support to its participating laboratories and, in turn, has its own performance monitored through participation in another EQA programme. Another model may encourage TTI screening laboratories to participate in as many EQA programmes as is feasible to challenge their systems as comprehensively as possible. Accreditation: Procedure by which an authoritative body gives formal recognition that an organization is competent to carry out specific tasks – ISO 15189:2013 E X T E R N A L Q U A L I T Y A S S E S S M E N T 7 Nevertheless, in this model, the principle of the EQA organizing institutions having their own performance assessed still remains paramount. Based on country needs, WHO advocates establishment of EQA programmes at the regional, national or provincial levels with the aim of facilitating participation by all laboratories undertaking TTI screening of blood donors, irrespective of the type of institution with which they are associated. When establishing an EQA programme, it can be helpful to seek information and support from WHO or other well-organized EQA programmes. At national level, it is advisable to investigate existing EQA programmes in other areas of pathology and the possibility of sharing of organizational infrastructure, facilities and resources. Figure 1: Network of EQA schemes Blood transfusion services City / State / Provincial / District Regional International National Hospital blood banks Other laboratories International 82 Establishing EQA programmes for TTI screening The establishment of an EQA programme could be initiated by the national health authority, blood transfusion service, professional body or interested individuals. An organizing institution and a team of individuals within the institution should be identified to manage and operate the programme. An advisory committee should be constituted to oversee the establishment of the programme and provide guidance on planning and organization. An effective EQA programme requires the commitment and support of the national health authority or authorities, professional bodies, the organizing institution and relevant staff, the supplier of material for EQA exercises and participating laboratories. The success of the programme depends on the trust and cooperation of all involved. In particular, the involvement of participating laboratories is vital in the organization of the programme. The roles and responsibilities of all involved should be clearly defined in order to ensure the effective operation of the programme. 2.1 ORGANIZING INSTITUTION The organizing institution should be a reputable institution with suitable facilities and expertise in the relevant field. Ideally the institution should be designated by the ministry of health and have access to funds allocated specifically for the operation of the EQA programme to ensure the programme’s independence and sustainability. Organizing and managing an EQA programme requires a large commitment of time and must therefore be adequately recognized and resourced if the programme is to be successful. To avoid any conflict of interest, an organization with commercial interests in supplying laboratory equipment or reagents should not be designated as the organizing institution. Establishing an EQA programme provides an opportunity for the organizing institution to become part of a network of laboratories for the exchange of information; this may also bring recognition to the institution. The organizing institution should participate in a recognized international or regional EQA programme in the relevant field. It should be able to demonstrate satisfactory performance and also show that an effective quality system is in place. The organizing institution should strive for international accreditation to ISO 17043:2010: Conformity assessment: general requirements for proficiency testing. E S T A B L I S H I N G E Q A P R O G R A M M E S F O R T T I S C R E E N I N G 9 The facilities and resources required to implement an EQA programme include:  space  different test kits and methodologies  access to supplemental or confirmatory testing  equipment  staff  technical support  administrative support  reliable source of exercise material  information management system  adequate funding. Ideally, all the required facilities and resources will be provided by the organizing institution. However, it is important to avoid compromising the quality of the programme by attempting to obtain all the resources from within one institution, if this is not feasible. If facilities such as logistical support need to be sought from different institutions for an EQA programme, an effective system of coordination will be required. Within the organizing institution a team of appropriately qualified individuals with a designated leader (EQA programme team leader) should be dedicated to providing the EQA programme. (Hereafter this team of individuals will be referred to as the EQA programme provider.) The EQA programme provider should have extensive experience and knowledge of best-practice TTI screening, and be aware of common approaches in different types of laboratories. In-depth knowledge and understanding is crucial to ensure the planning of effective exercises, as is insight into possible causes of error and ability to offer effective advice when required. Responsibilities The EQA programme team leader is responsible for the general management, operation and ongoing development of the programme, including the following activities: 1. General management:  identifying the number of staff required and their training needs;  selecting staff and allocating staff time;  financial management of the programme;  convening advisory committee meetings;  communicating with suppliers, participating laboratories, the advisory committee, regulatory authorities, the media and, where applicable, accreditation authorities;  selecting laboratories to conduct confirmatory testing or validate programme exercise material if necessary;  ensuring the provision and use of a suitable information management system (manual or computerized) for the programme to collate participant information and results; 10 S E C T I O N 2  implementing, maintaining and auditing the programme’s quality system;  preparing annual reports;  preparing annual financial statements if necessary;  handling complaints and taking corrective action;  attending and presenting data at meetings of participating laboratories and conferences;  promoting the programme. 2. Operation of the programme:  devising exercises and sourcing exercise material;  distribution of the exercise materials;  keeping track of results return and sending reminders;  verifying data entry, analysing results, assigning scores and preparing individual and composite reports;  reporting to participating laboratories any identified problems and advising on ways of improving performance;  providing troubleshooting advice to participating laboratories;  reporting to the ministry of health on de-identified laboratory performance and any issues with policy implications;  monitoring trends in laboratory and test kit performance;  maintaining up-to-date information about participating laboratories. 3. Ongoing development of the programme:  keeping up to date with developments in transfusion laboratory practice in TTI testing;  initiating and implementing changes, as required, to ensure the continued relevance of the programme;  exploring improved methods for data management and provision of information;  developing the education and training function of the programme. 2.2 ADVISORY COMMITTEE An advisory committee is invaluable in the design, planning and implementation of the programme. The membership of the advisory committee should comprise:  EQA programme team leader;  selected experts in the relevant discipline;  representatives of: — national blood centre — participating laboratories — professional bodies — confirmatory laboratories, if used — health and regulatory authorities. Once the EQA programme is established, the advisory committee should continue to give direction for its effective continuation. E S T A B L I S H I N G E Q A P R O G R A M M E S F O R T T I S C R E E N I N G 11 To ensure effective decision-making and communication, the size of the committee should be limited and members who will participate actively should be selected. The number and timing of advisory committee meetings will depend on the size of the programme and the frequency of the distribution of exercises, but at least two meetings per year will be required. The committee should make annual plans in advance for the aims of the exercises to facilitate the procurement of exercise material. Members of the advisory committee should maintain confidentiality of programme information, including any details about the exercises, especially if their own laboratory participates in the programme. Functions and responsibilities The functions and responsibilities of the advisory committee include: 1. Setting policy on:  strategy and direction of the programme;  rules of participation;  analytes and markers to be included for assessment;  ensuring regulations are in place for safe transport of exercise material;  principles of scoring and defining poor or unsatisfactory performance;  action to be taken on unsatisfactory performance;  reviewing complaints;  actions to be taken to rectify lost or damaged panels;  promotion of the programme;  role of the programme in education and training;  providing a source of independent expert advice to help poorly performing laboratories. 2. Providing professional and scientific guidance on operational matters, including:  planning the aims of each exercise;  establishing the algorithms by which exercise material is characterized;  establishing the methods by which the reference results are determined;  agreeing on the content of reports;  reviewing laboratory performance in each survey;  dealing with specific questions;  reflecting the views of participating laboratories;  promoting the educational and training role of the programme. 2.3 TECHNICAL AND ADMINISTRATIVE SUPPORT Adequate technical and administrative support is required to ensure adherence to the EQA programme schedule. This may be obtained within the organizing institution by the redesignation of existing staff, 12 S E C T I O N 2 the appointment of suitably qualified staff or by contracting to outside agencies. Technical and administrative tasks include:  acquiring and characterizing material;  processing material;  testing exercise material to ensure its suitability and documenting the results;  dispensing and labelling exercise material;  packing and dispatching questionnaires, exercises and final reports;  organizing couriers and postal services;  entering and analysing results and other information;  invoicing participating laboratories for registration fees, if applicable. 2.4 INFORMATION MANAGEMENT SYSTEM The requirements for information processing will depend on the scale and scope of the programme. It is possible to operate an EQA programme without any information technology, but the use of a computerized system makes essential tasks such as producing results forms much easier and allows for a more complex analysis of results. It is essential to be able to:  create a database (manual or electronic) of the details of participating laboratories, including contact names, addresses, confidential registration codes and tests to be assessed;  prepare exercise documentation, including letters, instructions, results forms and address labels;  record the results from participating laboratories, using confidential registration codes;  perform basic analyses, including comparison of each individual participating laboratory’s results with the expected results and the collation of the overall results;  analyse results within defined groups, such as laboratories using a particular technique;  prepare reports with the expected results, the individual results of each participating laboratory and other overall analyses or comments. It is desirable to be able to:  report data in different formats, such as histograms and scatter charts;  generate scores for performance monitoring and cumulative scoring;  search the database using specified criteria. Specialized computer software is available or can be developed, but many of these functions can also be achieved by the use of standard commercial software packages. E S T A B L I S H I N G E Q A P R O G R A M M E S F O R T T I S C R E E N I N G 13 2.5 FINANCES The resources required to establish and operate an EQA programme must be identified, the costs estimated and funding sought. Tables 1 and 2 show the broad categories of capital and recurrent costs and examples of the facilities and resources required for the establishment and operation of an EQA programme. Possible sources of establishment funding include government, health authorities, professional bodies, nongovernmental organizations and organizations providing research funds. A regular source of funds will be required for the ongoing and successful operation of the programme. An EQA programme could recover all or part of the operational costs by charging a fee to participating laboratories. While paying a fee may make participating laboratories appreciate the programme, the fee amount needs to be such that it is not a barrier to a laboratory’s participation. Health authorities should allocate adequate resources to ensure the programme’s sustainability, allowing the contribution from laboratories to be affordable. Care should be exercised if commercial companies are involved, as the programme should be seen to be independent. Category Examples Accommodation  Purchase or lease of premises or modifications to an existing building for: — office — laboratory — cold storage — packing and distribution facilities — record storage Staff  Recruitment  Initial training, if necessary Capital equipment  Laboratory: — water purification system — centrifuge — incubator — refrigerator — freezer — TTI test kit-specific equipment, e.g. microtitre plate washer and reader  Processing and dispensing: — magnetic stirrer — lyophilizer (optional) — laminar flow cabinet — clamp stands — pump — racks  Storage, package and dispatch: — cold room or refrigerator — heat sealer  Office: — photocopier — telephone — fax  Information technology: — computer Table 1. Initial capital costs 14 S E C T I O N 2 Pilot study  Raw material and staff time for: — study design — processing — dispensing and dispatch — analysis and reporting IT consultancy (optional)  Design of software programs for: — registration — invoicing — analysis of results — production of reports Category Examples Accommodation  Rent  Maintenance  Overheads Staff  Salaries and benefits  Training and education  Travel and related costs  Conference fees Equipment  Maintenance contracts  Replacement and repairs Exercise material  Raw material — acquisition — processing, including filtration Laboratory testing  Reagents  Consumables, e.g. tubes and pipettes Office  Telephone  Stationery  Consumables for printing and photocopying Information technology  Development of software  IT support  Internet connection Dispensing, packing and dispatch  Bottles  Packaging  Postage, courier Meetings  Advisory committee  Annual meeting of participants  Workshops Consultancy fees  Statistician  IT development  Transfusion specialist 2.6 QUALITY SYSTEM OF THE EQA PROGRAMME It is essential that the EQA programme itself has a good quality system. Elements of the organizing institution’s own quality system could be utilized for this purpose. It will, however, be necessary to implement a specific, effective quality system for the programme, with a quality policy stating how it will provide EQA services to meet the needs of participating laboratories. This policy should be included in the programme’s quality Table 2. Continuing recurrent costs E S T A B L I S H I N G E Q A P R O G R A M M E S F O R T T I S C R E E N I N G 15 manual, with references to all processes and procedures in the quality system, including those specific to the EQA programme and those in common with the organizing institution. There are a number of different processes involved in organizing an EQA programme. Therefore, it is important to ensure that appropriate documents and records for each step of the programme exercise are generated for traceability. These include quality plans, standard operating procedures, production protocols, worksheets, checklists, forms, exercise material characterization results, test kit interpretations, and details and results reported by participating laboratories. All documents and records must be kept confidential, stored securely and be readily accessible. The EQA programme provider may consider the following mechanisms to demonstrate quality of processes:  WHO/CLSI/CDC Laboratory quality management system: handbook  ISO 15189:2012 Medical laboratories: requirements for quality and competence  ISO 17043:2010 Conformity assessment: general requirements for proficiency testing  ISO 9001:2008 Quality management systems: requirements  ISO 17025:2005 Accreditation for testing and calibration laboratories  Continuing and satisfactory performance in an appropriate international EQA programme. 2.7 PARTICIPATING LABORATORIES When organizing an EQA programme, the advisory committee should define the profile of laboratories that should be encouraged or required to participate. The programme should be actively promoted to encourage full participation, but the most effective mechanisms for promotion will depend on whether it is a voluntary or mandatory programme. It is important to be aware of the number and type of laboratories that intend to participate, as this will have an impact on the organization of the EQA programme. Potential participating laboratories should be sent a preliminary questionnaire to identify:  staffing levels  overall workload  range of tests routinely undertaken  techniques and reagents used  quality system in place. This information can be used to ensure a suitable design for the format of EQA exercises (section 4) and may be also be useful for categorizing laboratories for performance monitoring (section  6). An example of a preliminary questionnaire to obtain general information about participating laboratories is included as Annex 1. 16 S E C T I O N 2 2.8 PILOT STUDY A pilot study should be undertaken to test the structure of the EQA programme, proposed methods of operation and design of exercises. The purpose of a pilot study is to expose any unforeseen logistical problems and identify solutions before scaling up the operation of the programme and offering formal participation. At least two pilot exercise distributions should be sent to a limited number of participating laboratories. These laboratories should be selected to represent different groups of participants in terms of their distance from the organizing institution, the size of their laboratories or the techniques they use. Participating laboratories should be asked to comment on any problems they encountered and to make suggestions for improvement. At the completion of the pilot study, a review should be made of problems experienced in the operation of the programme and comments from participants. Adjustments can then be made to the design of the programme and to the estimate of operating costs, if necessary. 2.9 PRACTICAL STEPS IN ESTABLISHING AN EQA PROGRAMME An outline of the practical steps to be taken in establishing an EQA programme is shown in Figure 2. Detailed discussion of each of these steps is found in the ensuing sections. E S T A B L I S H I N G E Q A P R O G R A M M E S F O R T T I S C R E E N I N G 17 Figure 2. Steps in establishing an EQA programme Identify organizing institution Identify organizing institution Identify established EQA programme for advice and support Set up advisory committee Identify source(s) of funds Identify potential participating centres Identify source and storage of exercise material Send preliminary questionnaire to all potential participating centres Invitation letter Design exercise format, based on information provided Identify distribution mechanism Conduct pilot study Develop systems for preparing and distributing exercises, handling results and performance monitoring Evaluate pilot study and make modifications, if necessary Promote the programme and register participating laboratories Implement the programme Monitor and evaluate the programme 18 3 Participating laboratories In order to participate effectively in an EQA programme, participating laboratories should recognize the need for quality and the role of EQA within a quality system in the TTI screening laboratory. Understanding the benefits of EQA and the way in which the programme works will encourage compliance with the rules of participation. This will enhance the value of the programme to the individual participating centres and the overall quality of the information generated. All staff in participating laboratories should have access to the EQA reports distributed by the programme. Any problems identified should be discussed openly in regular meetings and dealt with as problems relating to laboratory procedures and practices rather than as criticism of individual members of staff. Analysis of the root causes of errors in EQA provides the opportunity for participating laboratories to implement changes to prevent similar errors being made. Once the programme is established and open to participation, a formal registration process is required in order to gather contact details and other essential information from participating laboratories and also to provide them with the information they need for effective participation. This information should be provided in the form of an EQA programme information manual. The EQA programme provider may also consider organizing seminars for potential participants to explain the programme. 3.1 EQA PROGRAMME INFORMATION MANUAL An information manual should be developed to explain the management and operation of the programme and give practical instructions for participation. The information manual should be distributed with a registration form. The information manual should include:  aims of the EQA programme;  description of and contact details for the EQA programme provider;  details of the advisory committee;  explanation of the commitment needed from participating laboratories and the benefits of participation;  rules of participation;  description of the exercises offered;  explanation of the performance monitoring and scoring system; P A R T I C I P A T I N G L A B O R A T O R I E S 19  definition of unsatisfactory performance and action to be taken in the event of unsatisfactory performance. 3.2 RULES OF PARTICIPATION Clear rules of participation in the programme should be determined by the advisory committee. These rules should set out:  what is expected of participating laboratories;  the service to be provided by the programme;  how the information collected, including performance data, will be used. Participating laboratories should agree to these rules at the time of registration. Examples of rules of participation are given in Boxes 1 and 2. To maximize the benefit to participating laboratories and ensure the validity of programme data:  Only those techniques and technologies that are used in routine algorithms should be used to test the EQA exercise material.  EQA exercise material should not be tested only by the most senior or experienced staff.  EQA exercise material should be tested alongside routine specimens; it should not be kept aside for testing separately.  Exercise material should not be tested more than once and the results compared unless all specimens are also routinely tested in this way.  Excess exercise material may be used for other purposes such as staff training or competency assessment once the EQA results have been submitted.  Results must be returned by the closing date specified for the exercise.  There must be acceptance of agreed procedures for performance monitoring and follow-up of unsatisfactory performance.  Copyright of programme data must be observed to ensure that they are not published or presented out of context; permission must be sought from the programme provider or advisory committee before data are used. Box 1. Example of rules for laboratory participation in an EQA programme 20 S E C T I O N 3 To ensure the effective operation of the programme:  The confidentiality of performance data must be maintained between the programme provider, the advisory committee and the participating laboratory, unless there is an obligation by legislation or prior agreement for them to be disclosed to a third party.  Exercise material provided should have reliable quality.  There must be a clear time scale for the distribution of exercises and the return of the report.  The exercise material must be safe.  EQA programme reports must include suggestions for improving performance.  The EQA organizer must be available to address participating laboratories’ questions or concerns.  Exercise material must not be sent to another laboratory for testing, or communication entered into with another participating laboratory about the results. 3.3 REGISTRATION At registration, all interested laboratories should be sent a registration form, together with the information manual. The registration form should request the following information:  Contact details for the delivery of exercise materials and reports: — name of the participating laboratory — name of contact person — full postal address — telephone number — fax number — email address, where available.  The name and address of an additional person such as the head of participating laboratory or institution may be given for correspondence regarding performance, if required.  The relevant tests used by the participating laboratory and on which it wishes to be assessed should be included, enabling the programme to identify the tests for which exercise results can be expected from each laboratory. Ideally, participating laboratories should be assessed for all tests that they routinely perform. The registration form should also include a section to be signed by the participating laboratory, indicating its agreement to abide by the rules of participation. Examples of registration forms are included in Annex 2. Each participating laboratory should be allocated a confidential registration code for use in correspondence with the programme to ensure confidentiality of results and performance data. This code and the information on the registration form for each laboratory should be entered into the programme’s information management system. If a Box 2. Examples of rules for the programme P A R T I C I P A T I N G L A B O R A T O R I E S 21 computer database is used, each component of these details (such as the registration code and each line of the address) should be entered as separate fields to facilitate searches on the data. Information on participating laboratories should be kept up to date by annual re-registration; a new registration form should be distributed with a copy of the current registration details for confirmation. This will enable the programme to obtain updated technical information and contact details. 22 4 Practical considerations in establishing an EQA programme Information obtained from the preliminary questionnaires completed by potential participating laboratories should be used to design EQA exercises. Whenever possible, each EQA exercise should have an educational function, exploring areas where wide variation in testing is known to occur or suspected to be challenging to laboratories. The following practical aspects of the programme should be considered during its design:  scope  EQA programme and exercise format  objectives of the programme  sourcing and processing exercise material  exercise documentation  analysis and communication of results. 4.1 SCOPE A TTI EQA exercise should meet the needs of the participating laboratories and assess the tests routinely performed for screening of donated blood. This can be ascertained from the laboratories’ responses to the preliminary questionnaire. Screening for markers such as HIV-1/2 antibodies, hepatitis C antibodies, hepatitis B surface antigen and Treponema pallidum antibodies may be considered standard in a TTI laboratory and therefore should be included in EQA programme exercises. Depending on the scope of testing of the participating laboratories and the national regulatory requirements for screening of TTI, the markers included may be expanded to include HIV-1 p24 antigen, hepatitis B core antibodies or other markers such as Trypanosoma cruzi, malaria and HTLV-I/II antibodies. 4.2 EQA PROGRAMME EXERCISE FORMAT The number of EQA exercises to provide in a year should be sufficient to allow adequate assessment of laboratory procedures and practices and to gather sufficient data for cumulative performance monitoring. At least two exercises should be distributed to participating laboratories each year to give a minimum level of confidence in the laboratories’ performance. P R A C T I C A L C O N S I D E R A T I O N S I N E S T A B L I S H I N G A N E Q A . . . 23 The number of exercise materials that will be included in an EQA exercise should enable detection of potential errors in laboratory processes. An exercise consisting of a small number of materials (for example 1–4) may be able to detect random errors but will have limited capacity to detect systematic errors. Panels that consist of a larger number of exercise materials (for example 5–10) will have greater capacity to detect both random and systematic errors. 4.3 EQA PROGRAMME OBJECTIVES Each EQA exercise should address specific questions or objectives; the EQA panel should be constructed to address these objectives. A good EQA programme will provide participating laboratories with education on good laboratory practice and will be able to identify different laboratory errors that may occur. Some possible objectives and mechanisms are shown in Table 3. Objective Mechanism Can the participating laboratory correctly identify the status of specimens? Do the participating laboratory’s results match the reference results? Does the participating laboratory follow the manufacturer’s kit protocols? Collect details of testing on the results form, for example variations in test kit control results, reading time Does the participating laboratory produce consistent results? Include replicates of the same exercise material Does the participating laboratory produce consistent results over time? Include replicates of the same exercise material over different exercises Does the participating laboratory have a process for rejecting unsuitable specimens? Include haemolysed or other unsuitable exercise materials and assess if the participating laboratory proceeds to test the materials Can the participating laboratory identify administrative errors? Include exercise materials that have been purposely mislabelled Compare performance of different testing systems Analyse the results according to different systems and technologies Verify coverage of mandatory screening for TTI Include all mandatory markers Check the laboratory report 4.4 SOURCES OF EXERCISE MATERIAL Exercise material should preferably be obtained from blood transfusion services, since donor blood is ideal as exercise material. It is readily available in large volumes and is tested for TTI in accordance with local regulations. However, the ethics surrounding its use should be clarified. Ideally, informed consent should be obtained from the donors to use their blood for EQA purposes. Finding the required number of donations positive for TTI could prove to be difficult. When no suitable donor material is available and patient material has to be used, informed consent must be obtained. Table 3. EQA programme objectives and mechanisms Exercise materials: Materials that have been prepared from samples and that make up an EQA panel. Panel: A set of EQA exercise materials. Sample: A specimen, preferably of large volume, that has been processed, tested, and stored in a sample bank for potential use as exercise material. Specimen: Discrete portion of a body fluid, breath, hair or tissue taken for examination, study or analysis of one or more quantities or properties assumed to apply for the whole (ISO 15189:2013). 24 S E C T I O N 4 Blood transfusion service algorithms may prescribe that donations reactive on a TTI screening test kit are discarded, that is, confirmatory testing is not performed. In those cases, the reactivity may be true or false, and if the donations are to be used as exercise material, confirmation may be undertaken by the EQA programme provider or a designated expert laboratory. Efforts should be made to ensure that donations provided as potential exercise material confirm as positive when confirmatory testing is undertaken. This is important because of the costs involved in transporting plasma packs in accordance with regulations and in confirmatory testing. These investments are wasted if the reactivity of plasma packs is not as expected. Measures the programme provider can implement include:  Consider the prevalence of the TTI in the donor population from which the plasma packs are being sought. Preference should be given to obtaining plasma packs from blood transfusion services where the prevalence of the particular TTI is higher, so the positive predictive value of the reactive result in the screening test kit is higher.  Choose suppliers with good quality systems in place so that the quality of their test results can be trusted. Suppliers of exercise material should be selected according to their ability to make reliable provision of the quantity of material required and assure its quality. There should be a formal agreement between the EQA programme provider and the supplier or suppliers to ensure that the supply of exercise material is reliable and meets all the specifications set by the programme. It is essential that the EQA programme provider or an expert laboratory, if used, is able to characterize the exercise material accurately, even if participating laboratories are not required to undertake extensive testing (see section 5.3 on the selection of exercise material). Candidate samples for TTI exercise material may be organized into a “sample bank” – a repository of a large number of large-volume samples with varying characteristics. This is possible because, in the case of TTI, the most common exercise material is plasma or serum, which can be stored frozen for prolonged periods without compromising its serological reactivity. Significant and ongoing resources are required to establish and maintain a sample bank. 4.5 ESTABLISHING A SAMPLE BANK Establishing a TTI sample bank for serum or plasma to be used as exercise material should be commenced well in advance of the first EQA programme exercise. Candidate sera and plasmas should be processed in a timely manner and stored appropriately. Upon receipt, a unique laboratory identification number should be allocated to each serum and plasma. A candidate serum or plasma obtained in large volume should be dispensed into smaller practical volumes aimed at reducing the number of freeze/thaw cycles. Serum and plasma should be stored frozen at or below –20°C in polypropylene containers of appropriate volume with leak- proof screw lids containing a sealant such as an O-ring. P R A C T I C A L C O N S I D E R A T I O N S I N E S T A B L I S H I N G A N E Q A . . . 25 The containers should be clearly labelled using high-quality adhesive labels. The exercise material should be carefully characterized through validated testing strategies to determine the true serological status of the material, and the information stored in a database (see subsection on characterizing and testing EQA exercise material, in section 4.6). A sample bank database is an inventory of biological material in a repository. The information in the inventory should be updated on a regular basis, as it will need to be accessed each time an EQA exercise is planned. The type of information that should be recorded in a sample bank database includes:  unique laboratory identification number  reference number or code  date collected  date received  type of material (e.g. serum, plasma)  volumes and number of vials (if dispensed into smaller volumes)  clinical information and provider’s test results  characterization test results  location in sample bank freezer  sample tags2  number of freeze/thaw cycles. Once the sample bank is established, it is recommended that allocation of resources continues in order to maintain the appropriate number and volumes of exercise materials required for future EQA exercises. 4.6 PROCESSING CANDIDATE EXERCISE MATERIAL Although plasma is an appropriate biological material for TTI EQA exercises, there are aspects that must be considered when it is used as EQA exercise material (for example limitations in volume, and formation of clots regardless of filtration or centrifugation steps). In some cases defibrinated plasma or serum may be considered as an alternative to plasma. Which biological material to use as TTI EQA exercise material should take into account the needs of the participating laboratories and the validity of the material for use in TTI test methods. Manipulations may be performed to increase the volume or quality of biological materials used for EQA exercises. It should be stressed that EQA exercise materials should be as representative of “normal” donor specimens as possible. Each manipulation performed will cause deviation from “normality”. Further, a manipulation may have an adverse effect on the results produced by different test methods. Thus, each method of manipulation should be extensively validated for its effect before applying it to EQA exercise material. 2 It is useful to consider the allocation of a “tag” or code to each serum or plasma to help search and identify materials in the database. 26 S E C T I O N 4 Conversion of plasma to serum Plasma collected in donor collection bags will contain an anticoagulant such as citrate-phosphate-dextrose (CPD), and thus conversion to serum naturally is not possible. However, plasma can be converted to defibrinated plasma (in effect serum) by artificially initiating the clotting cascade through the addition of thrombin followed by removal of the resulting clot. Once the clot is removed, microfiltration of the serum should be considered to remove any bacterial contamination.3 Filtration Biological materials can be filtered using either vacuum or pressure filtration apparatus, in a stepwise reduction of pore size (prefilter, 0.8 microns, 0.45 microns and a final 0.22  microns). Filtration will remove any microparticulate matter, ranging from microclots to bacterial contamination.4 As a note of caution, the conversion of plasma to serum and filtration processes are cumbersome, labour intensive and potentially hazardous. Therefore, these processes should be conducted in biohazard cabinets by personnel with adequate personal protective equipment including gowns, gloves and face masks or goggles. Nevertheless, effort must be made to provide exercise material free of contamination, particulate material and clots. Without conversion of plasma to serum, reasonably satisfactory exercise materials can be produced by centrifugation of the material to remove particulate matter and clots. To maintain sterility without filtration, exercise material should be handled in a class II biosafety cabinet, paying attention to aseptic techniques to the extent possible and using sterile equipment and containers. Use of biocides The use of biocides may be considered to reduce the potential for bacterial growth and preserving the quality of the biological material. An example of a biocide is ProClin 300 (1.5% methylisothiazolinone, methylchloroisothiazolinone). Sodium azide, which was once used extensively as a biocide, is no longer recommended owing to safety concerns. Thorough validation of any biocide should be undertaken to identify potential interference with TTI test methods.5 Pooling For large EQA programmes, pooling can be considered an option for increasing the volume of exercise material available (where the volume 3 Ratnoff OD. “An accelerating property of plasma for the coagulation of fibrinogen by thrombin”, Journal of Clinical Investigation. 1954;33:1175–82. 4 Bobbitt JA, Betts RP. “The removal of bacteria from solutions by membrane filtration”. Journal of Microbiological Methods. 1992;16(3):215–20. 5 ProClin: http://www.sigmaaldrich.com/content/dam/sigma-aldrich/docs/SAFC/ General_Information/proclin_efficacy.pdf. P R A C T I C A L C O N S I D E R A T I O N S I N E S T A B L I S H I N G A N E Q A . . . 27 requirement for the number of participants exceeds that normally found in a single blood donation). Pooling samples involves mixing individual samples together to create a mixed pooled sample. However, in pooling samples, a dilution effect may be created – in other words, dilution of the individual constituents of each sample used in the pool. This risk may be reduced by selecting samples of similar antibody or antigen profiles, as ascertained by testing, thus only pooling samples with similar test result profiles or characteristics. Pooling has the benefit of extending the volume of exercise material while seeking to maintain the reactivity of key constituents in the samples contributing to the pool. Sometimes, pooled negative sera or plasmas can show an increased tendency to false reactivity. Therefore, pooled exercise materials, whether they are negative or positive, should be tested extensively before use in an EQA programme. Dilution Dilution with negative plasma or another isotonic diluent to create exercise materials should be avoided where possible. Dilution of biological material to increase the volume may be possible if the material is only diluted to the extent required to create the additional volume. Dilution to mimic early infection profiles or “weak” results creates a final exercise material that does not have a serological profile representative of that seen in undiluted donor specimens. In addition, the ability of some tests to detect diluted antibodies or antigens that would normally be detected when undiluted may be reduced. The EQA programme provider must test diluted exercise materials in a large number of test kits that are likely to be used in the programme to ensure that they behave as expected. Dilution of quantifiable markers – for example, hepatitis B surface antigen (HBsAg) or HIV-1 p24 antigen – may be considered as options to produce serological exercise materials representative of early infection, where it is difficult to find naturally occurring biological material of sufficient volume. In the case of HBsAg, care must be taken to not overdilute other early hepatitis B markers (anti-HBc IgM), should these be markers that the EQA programme is assessing. Further, the diluent must be free of hepatitis B surface antibody as it is likely to complex with HBsAg and render it unavailable in the testing system. Dried tube samples Transportation conditions are major contributors to poor-quality exercise materials. In addition, transportation costs may be too high, adding a financial burden to the EQA programme. Some EQA programmes for resource-limited settings are provided as dried tube samples (DTS). These are small volumes of positive or negative serum or plasma that have been dried in air over 12–24 hours.6 6 Parekh BS, Anyanwu J, Patel H et al. “Dried tube specimens: a simple and cost- effective method for preparation of HIV proficiency testing panels and quality control materials for use in resource-limited settings”. Journal of Virological Methods. 2010;163(2):295–300. 28 S E C T I O N 4 Only small volumes can be dried over this period (for example 20 microlitres), but the dried pellet is reconstituted in a ten-times greater volume, usually in phosphate-buffered saline, resulting in exercise material that is tenfold diluted and having a different matrix from true serum or plasma specimens. It is not advisable to use weakly positive samples in DTS EQA programmes because the dilution may cause false negative reactions in all or some test kits. The EQA programme provider must reconstitute and test the DTS in a large number of test kits that are likely to be used in the programme to ensure that the exercise materials behave as expected. Despite these different approaches that contravene conventional EQA norms, using DTS makes providing some form of quality monitoring possible in situations where conventional EQA programmes are not feasible. It must be noted that if DTS are provided as exercise materials for an EQA programme, the participating laboratories must reconstitute them before testing. This is an additional variable, the potential impact of which must be considered when analysing and scoring results. Characterizing and testing EQA exercise material The key attributes of exercise material in TTI EQA are:  that the specimen type is generally approved by the manufacturers of test kits that are used by the programme participants, for example serum or plasma;  that the exercise materials are homogenous, and stable for the period over which the exercise is under way;  that the true status of an exercise material is known for the markers under assessment. Instructions for use that accompany test kits for TTI usually specify the specimen types that are appropriate for use in the tests. It is important that the exercise materials provided in the EQA programme mimic as closely as possible a specimen type that is allowed by all the tests, otherwise aberrant results may be obtained if a specimen type differs significantly from those recommended. For example, as mentioned earlier, the appropriateness of phosphate-buffered saline reconstituted DTS as a specimen type must be confirmed by the programme provider as appropriate in all the test kits used by the programme participants. Characterization of samples is usually achieved using a testing strategy and a defined algorithm. A testing strategy defines the range and types of tests used to determine the status of a sample; an algorithm specifies the names of the tests and the order in which they are used. A testing strategy includes a first test to identify negative samples, and one or more supplemental tests that are used to confirm whether those samples that are reactive in the first test are positive or not. This confirmation of positive reactivity is performed because all tests for TTI give a small proportion of false positive results. Testing in a second test assists with ensuring that samples in the sample bank that are assigned a positive status are truly positive. The first test in an algorithm must be of high sensitivity, especially because it will identify negative samples, that is, a negative result from P R A C T I C A L C O N S I D E R A T I O N S I N E S T A B L I S H I N G A N E Q A . . . 29 the first test will be assumed to be correct and no other testing will be performed to “confirm” the material’s negative status before its status is assigned in the sample bank. Therefore the programme provider needs to be confident that the first test kit used to characterize sample bank samples is as sensitive as is available and will not misclassify positive samples that could be detected by other test kits used by laboratories participating in the EQA programme. The EQA programme provider needs to consider carefully the way sample bank samples are characterized. For example, if any participating laboratories have indicated that they use HIV combination assays, which detect both antibodies to HIV and HIV p24 antigen, the EQA exercise materials must be characterized for both of these markers. Similarly, if participating laboratories use specific or non-specific treponemal tests for syphilis, the status of the EQA exercise materials for both of these markers should be known. The key attributes to consider when choosing tests for characterization of samples and testing of EQA exercise materials are:  Tests available. Most countries will have a list of tests that can be procured for each marker.  Test characteristics. Information about a test’s performance (sensitivity and specificity), its ease of use, requirements for equipment, and other characteristics is necessary. Such information may be found on the WHO website.7 Peer-reviewed publications are another source of information.  Purpose of testing. An EQA programme provider may be performing testing for purposes other than characterization of EQA material. It is this testing that will drive the choice of tests, for example, what is the throughput of testing; what is the required turnaround time; what is the shelf life of the reagents; and is there access to refrigeration if necessary. 4.7 EXERCISE DOCUMENTATION Each EQA exercise requires accompanying documents, which may include:  instructions on how to handle, test and report results for the EQA exercise material;  results forms;  feedback questionnaires, included periodically to enable continual improvement of the programme. Exercise instruction sheets that are generated for each exercise should provide general information on how to handle, test and store the exercise materials and how to report the results to the EQA programme provider. The participating laboratories should be reminded to treat the exercise materials as routine specimens and subject them to the same testing and processes. The instruction sheets generally include the following information: 7 http://www.who.int/diagnostics_laboratory/evaluations/en/. 30 S E C T I O N 4  number and identifiers of exercise materials  exercise code  deadline date for returning the results  storage and handling instructions  testing instructions  reporting instructions  biological safety precautions  EQA programme provider contact information. An example of an exercise instruction sheet is given in Annex 3. The EQA programme provider should prepare a form for the collection of EQA exercise results. The EQA results form may be provided electronically or in paper form. Whichever mechanism is used, the form will allow for a standardized approach to collecting EQA test results and information from participating laboratories. A paper-based data collection form requires the EQA programme provider to design a results collection form that is sent to the participating laboratories with the exercise panel. Upon completion of testing for the exercise the laboratories must submit the completed results form to the EQA programme provider by mail or fax. This format is simple to develop and allows for flexibility in the information that can be provided by the participating laboratories. A disadvantage of paper-based data collection is that results from all of the participating laboratories must be collated by the EQA programme provider, a process that is time consuming and vulnerable to error. An electronic data collection form can be sent electronically to the participating laboratories. When the testing for the exercise is complete, the participating laboratory enters the results into the form and can return it to the EQA programme provider electronically. The EQA programme provider can then copy and collate the data electronically, reducing the time required for data entry. Although this format can reduce the likelihood of data entry error, validation checks are necessary to ensure that data have been copied accurately. A further adaptation of electronic data collection is an Internet-based format. This method requires the design and maintenance of an online data collection system. Participating laboratories can enter the EQA exercise results directly into the online database. In this format no data entry is required by the EQA programme provider, eliminating the time taken and potential for error at this step. A disadvantage of this data collection format is the need for resources to design and maintain a functional website. Furthermore, participating laboratories will require the information technology infrastructure to use the system. Whichever format is chosen for the collection of EQA exercise results, the results forms should generally include the following information:  participating laboratory code and name  receipt date and condition in which the exercise material was received  name of test method or reagents used P R A C T I C A L C O N S I D E R A T I O N S I N E S T A B L I S H I N G A N E Q A . . . 31  reagent lot number and expiry date  date of testing and name of person doing the test  test results and interpretations  additional comments. Examples of exercise results forms are given in Annex 4. 4.8 LOGISTICS Based on local infrastructure, the EQA programme organizer will need to decide upon the mode of transport for the EQA panels to be delivered to the participating laboratories. Health and safety issues should be considered for all groups of workers who may be exposed to exercise material, including postal and courier workers. These people must be trained how to handle the exercise material safely should the packaging be damaged or there is leakage. EQA programme exercises should be packed and labelled in conformity with local or international postal or air regulations, such as those of the International Air Transport Authority (IATA), as applicable. For IATA purposes, exercise materials can be shipped as diagnostic samples and not as dangerous goods. IATA regulations require specific triple packaging and labelling. In brief, vials containing exercise material are sealed in a watertight secondary package that contains sufficient absorbent material to soak up the total volume of exercise material within the package in case of leakage or breakage. The secondary package should be placed in further packaging that is capable of protecting the contents from physical damage while they are in transit (Figure 3). Figure 3. Schematic of triple packaging for IATA-compliant shipping of diagnostic samples The external packaging should be labelled to indicate that it contains pathological material. The name and address of the EQA programme should be written on the outside as well as the name and address of the participating laboratory to which the exercise material is being sent. Source: IATA, Montreal, Canada. 32 5 Planning and operating an EQA programme for TTI testing There are two types of plan required to guide the provision of an EQA programme. One is an annual plan, which describes the main features of the programme and the activities of the programme provider over a year of the programme. The other plan is a detailed description of the activities required from beginning of material production to the finalization of the EQA programme report. A plan of this type is required for each EQA exercise. 5.1 DEVELOPING AN ANNUAL EQA PROGRAMME PLAN Before the commencement of an EQA programme, the programme provider should identify and plan the processes for the EQA programme year. Plans should be documented and contain information that addresses the objectives and design for each exercise of the EQA programme year. Annual plans should contain references to standard operating procedures, protocols and other documents that contain more detailed information. Typically, annual plans for EQA programmes should address the following information:  name, address and contact details of the EQA programme provider;  name, address and contact details of subcontractors involved in the EQA programme, if applicable;  any specific objectives of the EQA programme for the year – for example, an annual objective could be to examine the laboratories’ abilities to obtain reproducible results on different occasions when testing the same materials;  activities to ensure samples in the sample bank are adequate to meet the needs for the year’s exercises;  the number and type of participants expected to be enrolled in the EQA programme;  participation fee or funding mechanisms;  information on what materials and analytes participating laboratories are to identify, measure or test for in each exercise of the EQA programme;  requirements for the production, quality control, storage and distribution of EQA exercise material; P L A N N I N G A N D O P E R A T I N G A N E Q A P R O G R A M M E F O R T T I . . . 33  schedules and dates for production of EQA exercises, dispatch to participating laboratories and deadlines for submission of results by participants;  procedures for homogeneity and stability testing;  description of the statistical analysis to be used if applicable and criteria for the evaluation of performance of participating laboratories;  expected dates when reference results and final reports will be made available to participating laboratories. 5.2 DEVELOPING THE PLAN FOR A SPECIFIC EQA EXERCISE While the annual EQA programme plan is a high-level document that defines broadly the attributes of the programme, a specific plan is required to guide the preparation of each EQA exercise. This more specific plan will document how each individual exercise will be executed. The specific plan should address the following information for each exercise:  responsibilities of individual staff in preparation of the exercise;  aim(s) of the exercise;  number of laboratories enrolled in the exercise;  selection criteria and volume requirements for each of the exercise materials to satisfy the aim of the exercise;  exercise name, panel number and code;  identifiers for individual exercise materials;  detailed production processes and verification testing;  schedule and dates for production of the exercise panels, dispatch to participating laboratories, and deadline for submission of results and report distribution;  references to protocols for homogeneity and stability specific to each exercise;  references to all documents, forms and records involved in the exercise. It is recommended that a process checklist and timeline be designed alongside the specific EQA exercise plan; this ensures that processes occur in a systematic manner and provides traceability of the entire EQA process. 5.3 SELECTION OF MATERIAL FOR EQA EXERCISES Appropriate samples that will satisfy the aims of the specific EQA exercise should be selected from the sample bank. Each exercise should contain materials that are of highest quality, each with a defined serological status, based on the characterization testing results recorded in the sample bank database (see section 4). An EQA exercise will consist of a number of negative and positive exercise materials. The number of negative and positive exercise materials and the order in which they are presented in the panel should vary from exercise to exercise to avoid the participating laboratories predicting the exercise composition. 34 S E C T I O N 5 Sufficient vials should be prepared to meet both the requirements of participating laboratories and to allow the programme provider to retain spare vials in storage. Spare vials are needed in case participating laboratories require replacements due to loss or breakage, or for repeat testing following an error. Additional vials will also be required by the programme provider for in-house testing throughout the duration of the exercise for stability purposes, for archiving or for future use. The total volume required for each exercise material is calculated by taking into consideration the following:  total number of participating laboratories in the exercise;  number of additional exercise panels that will be prepared (to be used as replacement panels or for investigation purposes);  number of vials of each exercise material required for homogeneity and stability testing;  volume required for each vial;  volume loss or error allowance during panel production (through centrifugation and dispensing). 5.4 PREPARATION OF EXERCISE MATERIALS Once appropriate samples have been identified, they are removed from the sample bank. The removal of the samples should be updated in the sample bank database. Samples will need to be thawed prior to use. For smaller volumes, plasma can be thawed in a water bath at 30–37°C, for as long as it takes to thaw (normally no more than 30 minutes). Thawing time will vary according to the temperature of the water bath and the volume of plasma.8 Once thawed, volumes of the same sample should be combined if the sample was stored in more than one vial. If pooled samples are to be used in the EQA exercise, the pooling process would take place during this stage. Separate aliquots of the same sample or aliquots of different samples identified for pooling must be well mixed before further processing. The total volume of each sample is centrifuged to pellet particulate matter and the supernatant decanted into a separate sterile vial. Each sample should be tested again before dispensing into individual vials to create exercise materials, and cross-checked with the original sample bank characterization results. This verifies that there has been no mix-up and that there has been no degradation during storage. If any results differ from those expected, the sample is not appropriate for use in the exercise and it is recommended to select an alternative sample. 5.5 DISPENSING EXERCISE MATERIAL Screw-capped external thread polypropylene vials of appropriate volume should be prelabelled prior to dispensing, with adhesive labels that have 8 Extended life plasma: a framework for preparation, storage and use, 2nd edition. Australian and New Zealand Society of Blood Transfusion Ltd; 2013. P L A N N I N G A N D O P E R A T I N G A N E Q A P R O G R A M M E F O R T T I . . . 35 been validated to demonstrate adherence to the vials through fluctuating temperatures and storage conditions. Adhesive vial labels should contain the following information:  EQA programme name  exercise number or code  identifier of the exercise material  volume of the material contained in the vial. It is recommended that the information on the labels be printed electronically if possible to minimize transcription errors. Labelling of all tubes for one exercise material should be segregated to avoid mix-up of labelled tubes. Dispensing all the vials for one exercise material should be completed before moving on to the next to reduce the risk of contamination, of mix-up between materials, or of dispensing into an incorrect vial. It is recommended that negative materials be dispensed first followed by positive materials. Manipulation of biological material is ideally performed inside a biological safety cabinet. Once exercise materials are dispensed into vials, the panels can be assembled into labelled panel packaging. Packaging labels should contain the following information:  EQA programme name  exercise number or code  number of exercise materials in the panel  recommended storage temperature  expiry date  biohazard symbols. The assembled exercise panels should be stored between 2°C and 8°C until ready for dispatch, which should occur as soon as possible after the production has been completed. 5.6 VERIFYING HOMOGENEITY AND STABILITY Regardless of the biological material used, it is necessary to ensure that exercise materials are adequately mixed and all participating laboratories receive equivalent material that is uniform in composition with minimal variation (homogeneous material). Verification of the materials’ homogeneity should be completed for each EQA exercise distribution. It is performed:  by testing a random selection of representative numbers of final vials of each exercise material;  after processing and dispensing of the exercise material into vials but before dispatch to participating laboratories. The number of vials chosen for homogeneity testing should be sufficient to assess possible variation in the exercise material. For each exercise material that has been dispensed an appropriate number of vials is selected randomly. ISO 17043 states: “Where appropriate, the provider or its subcontractors shall use a statistically random selection of a 36 S E C T I O N 5 representative number of samples from a batch of test material to assess the homogeneity of the material.” There is no defined number of vials required for homogeneity testing, though, as a guide, it is usual to select a minimum of 10% or 10 of the vials produced, whichever is the greater. However, the number of vials chosen for homogeneity testing should not exceed the capacity of a single test run to avoid interrun variation. It is important to ensure that the reactivity of the material has not changed in any of the vials selected and tested for homogeneity. An extensive homogeneity protocol must be undertaken and all records documented. For homogeneity testing, it is recommended that the first test method in the programme provider’s validated testing strategy for the appropriate marker is used. If a single vial does not produce the expected result, it may result in all vials containing the particular exercise material being removed from the exercise. An example of a protocol for homogeneity testing is included in Annex 5. 5.7 VERIFYING STABILITY It is necessary to validate the stability of materials in order to ensure that they are fit for use when they arrive in participating laboratories and no loss of material integrity has occurred. Temperature, time, biological material type, pathogen properties and other factors can contribute to loss of material integrity. The stability of materials can be tested by different mechanisms:  leaving vials unopened, at ambient temperature, for the length of time that exercise materials are expected to spend during distribution, followed by retesting to confirm reactivity;  conducting accelerated stability studies at different temperatures in the laboratory;  simulating real-time stability studies. Preparation and execution of a stability protocol will monitor and assess the rate of possible deterioration of the exercise materials. The stability of the exercise material should be monitored from the time of completion of EQA exercise material production through to, at least, the closing date of the exercise. The number of vials chosen for stability testing should be sufficient to allow testing to occur at regular intervals for the duration of the exercise. Regular monitoring will help pinpoint the time of deterioration, should it occur. It is recommended that stability continues to be monitored for a short period of time after the closing date of the exercise, in the event of any troubleshooting that may be required. Like homogeneity testing, it is recommended that the first test in the programme provider’s testing strategy for the appropriate marker to characterize the exercise material is used for stability testing. A stability protocol needs to be documented before the commencement of stability testing, taking into consideration the timeline of the exercise and factors that may influence the stability of the exercise material. Acceptance criteria must also be documented in the stability protocol outlining the actions taken if results show that the stability of an exercise material has deteriorated. In developing the acceptance criteria it is important to P L A N N I N G A N D O P E R A T I N G A N E Q A P R O G R A M M E F O R T T I . . . 37 allow for intrarun and interrun variation when analysing stability results. An example of a protocol for stability testing is included in Annex 6. Sending material to one or more distant participating laboratories that then return it for retesting is also sometimes used for stability testing. However, this only verifies the stability of the material while it is in transit, unless it is held at the participating laboratories for the duration of the exercise before it is returned. 5.8 PACKING AND DISPATCH Documentation appropriate to the specific EQA exercise should be included within the package. These include the instructions for handling the exercise materials and the forms for recording the results, if hard copy results forms are used. Although templates for this documentation will have been developed at the outset of the programme, it is important to proofread and check all documents before distribution to ensure that there are no contradictions, ambiguities or omissions in the information, and that the information pertains to the specific exercise being distributed. Accompanying documents should be sealed within a protective pouch and attached to the outside of the secondary package. If the EQA programme provider has decided to use electronic results forms, these should be emailed to the participants at the same time as the exercise materials are dispatched. A list of participating laboratories’ registration codes is helpful when packing exercises to ensure that no laboratory is missed. It is also important to have a protocol for packing, including checking that the correct combination of exercise materials and documents has been packed for each participating laboratory. Annex 7 contains an example of a record of exercise distributions and returned results that can be used as a packing checklist. If exercises are all distributed on a single day, it is sufficient to note the date and place a tick in the columns “Documentation packed”, “Materials packed” and “Exercise distributed” against each participating laboratory. The date of packing and distribution should be recorded for any participating laboratory to which exercises are sent on other dates. 5.9 COLLECTION OF AND DEADLINE FOR EQA RESULTS Participating laboratories are expected to submit the completed exercise results form to the EQA programme provider by the specified deadline date for the acceptance of results. Results received after this time should not be accepted, especially if stability validation processes do not extend beyond the deadline date. In order to encourage and remind participating laboratories, the EQA programme provider may contact participating laboratories a week before the deadline to remind participating laboratories to submit their results. Upon receipt by the EQA programme provider, the completed results forms should be date-stamped and filed in a manner that allows for easy retrieval. The EQA programme provider may choose to do a quick review of the results forms received to ensure the forms have been completed and that all information is legible and identify any gross errors. 38 S E C T I O N 5 5.10 COLLATION OF EQA RESULTS EQA exercise results from the participating laboratories should be collated in a manner that facilitates analysis. The approach for collating the results from an EQA exercise will depend upon how the data were collected and the type of data submitted. EQA exercise results should be collated in a single location that is a physically safe and confidential environment. Although manual-based collation of the results is possible, an electronic system is preferable to allow for ease of storage and analysis. It is essential that the EQA programme provider has a quality data management process in place. Manual-based systems will require higher levels of management to ensure that errors in transcription and data entry are minimized. The number of times data are handled should also be reduced to avoid errors. For both manual and electronic methods of results collation, secure data storage and maintenance of records (including adequate backup of electronica data) are required. The type of test results submitted by the participating laboratories (qualitative or quantitative) from one or more test methods needs to be considered in designing a system for collation and analysis. Whether each piece of supporting information (such as test method name, lot numbers, expiry dates, operator, test date, etc.) should also be included will depend on the way the data will be analysed. 5.11 ANALYSING EQA RESULTS In order to analyse the EQA exercise results, the reference result for each exercise material needs to be determined by the EQA programme provider. This reference result will usually be assigned based on characterization testing performed during the production of the EQA exercise material. However, occasionally, the reference result may be assigned based on a consensus of results from a group of laboratories. Ideally, this should occur rarely when an exercise material behaves in an unexpected manner and gives results that deviate from the characterization results. The reference results should be made clear to the participating laboratories. The complexity of the results analysis performed may depend on:  the maturity of the EQA programme and the technical knowledge of the EQA programme provider;  the aims of the EQA exercise;  the resources available to the EQA programme provider. Another important consideration is the time frame for providing feedback and reports to participating laboratories. Timely communication of laboratory performance in the EQA exercise may be more useful that an in-depth analysis that requires a prolonged time to complete. A simple approach to analysing EQA exercise results should highlight:  participating laboratories that reported results that differed from the reference results;  test methods that produced results that differed from the reference results. P L A N N I N G A N D O P E R A T I N G A N E Q A P R O G R A M M E F O R T T I . . . 39 Advanced approaches to analysing EQA exercise results may include:  investigating the performance of various test methods by grouping the data into subsets based on common test methods;  investigating the performance of the different reagent lots used by participating laboratories;  analyses of quantitative results using statistical tools. Each participating laboratory should receive an individual analysis of its performance for the exercise. The individual laboratory report should clearly highlight any results reported by the participating laboratory that differed from the reference results determined by the EQA programme provider. It is important to remember that only laboratory codes should be used when reporting or assessing the performance of participating laboratories, in order to maintain confidentiality. When analysing data sets or using statistical tools, it is important to be aware that making comparisons between small numbers of results may not be valid. 5.12 STATISTICAL ANALYSIS OF EQA EXERCISE RESULTS Quantitative results can be statistically analysed to determine whether any of the participants’ results for an exercise material differ significantly. To perform this type of analysis, data must be divided into like groups so that the data set analysed contains only results that were generated from the same test method (peer group). It is necessary to remove statistically outlying results that can skew the calculation of the average and standard deviation of a data set. Statistical methods for identifying outlying results include Grubbs’ test and Tukey’s filter.9 The summary statistics of the data set describing the mean, standard deviation and coefficient of variation can then be determined. This information provides the “target” values and allows a participating laboratory to compare its performance with that of the other participating laboratories using the same test method. EQA programme providers should consider that when the number of results in a data set is less than five the statistical profile generated may not provide an accurate representation of the results expected for the sample on that test method. Therefore, for small data sets, reporting a statistical profile is not useful or appropriate. Robust statistics are also commonly used for analysing EQA peer group results and are recommended by ISO 13528:2005, Statistical methods for use in proficiency testing by interlaboratory comparisons. 9 Barnett V, Lewis T. Outliers in statistical data, 3rd edition. Wiley; 1994. Tukey’s filter: http://www.statisticshowto.com/tukey-iqr-test/. 40 S E C T I O N 5 5.13 PREPARATION OF EQA REPORTS The outcomes of the analysis of results submitted for the exercise should be documented in a report that is made available to all of the participating laboratories. To maintain confidentiality of the participating laboratories, only identification codes should be used within the report. In this way information about the overall quality of testing among the participating laboratories can be communicated without breaching confidentiality. A short turnaround time for providing the EQA exercise report to the participating laboratories is a priority. An EQA exercise captures a snapshot of each participating laboratory’s performance at a particular point in time. Prompt feedback allows participating laboratories to investigate and take necessary corrective action on any identified deficiency whilst the problem is still relevant for the laboratory. Delays in feedback about performance may reduce the value of extensive analysis of the results performed. In situations where prompt feedback is unachievable for the EQA programme provider, an alternative procedure of sending out a preliminary report soon after the exercise closure, followed by the exercise report at a later date, may be acceptable to the participating laboratories. 5.14 PRELIMINARY REPORT The preliminary report is a summary of the composition of the materials in the EQA exercise. It does not contain any analyses of results, and hence can be prepared in advance. A preliminary report should contain:  the EQA exercise name, date and code;  characterization test results;  the reference results assigned to each exercise material. The information in the preliminary report allows participating laboratories to promptly review their performance in the exercise and implement corrective action if necessary. 5.15 FINAL REPORT The EQA exercise report should contain the following information:  the name and contact information for the EQA programme provider;  the name and code of the EQA exercise;  a description of the materials provided in the EQA exercise, including production methods and details of how the reference results were obtained;  the characterization test results for each exercise material;  the aims of the EQA exercise;  a description of the data analysis methods used;  the number of participating laboratories in the exercise;  individual assessment of participating laboratory results, highlighting those that differed from the reference results. In addition, the following information can enhance the value of the EQA programme: P L A N N I N G A N D O P E R A T I N G A N E Q A P R O G R A M M E F O R T T I . . . 41  a summary of the results reported for each exercise material by test method used;  systematic problems relating to a specific test method or reagent lot number used by participating laboratories;  advice to participating laboratories on how to troubleshoot laboratory errors;  general comments and discussion on the results submitted for the exercise. Care needs to be taken to make the EQA exercise report clear and informative. Developing a template that forms the basis of the report ensures consistency of the information delivered for each exercise and increases the efficiency of the report writing process. Comments and recommendations made by the EQA programme provider about the results submitted for an exercise should be non-judgemental, constructive and evidence based. The report of the EQA exercise can provide advice and suggestions for preventive action when reasons for error are able to be deduced. Depending on the type, frequency and severity of errors detected in EQA exercises, the programme provider may choose to offer additional action to assist a participating laboratory to rectify its testing processes (see section 6). Examples of a preliminary report and analyses that can be included in the final EQA exercise report are included in Annex 8. 5.16 CERTIFICATES OF PARTICIPATION Participation in EQA programmes is an important element of a laboratory’s quality management system. As such, laboratories may be required to demonstrate evidence of such participation and their performance. Although EQA reports and demonstration of corrective action following identified errors in EQA are the best evidence, many participating laboratories may also request a certificate of participation. The issue of an annual certificate of participation, detailing the number of exercises undertaken, can be a positive means of encouraging continued participation. Certificates of participation may be issued in a number of ways. For example, certificates may be issued after each EQA programme exercise or yearly. The EQA provider will need to define what constitutes “participation”. Certificates may be granted for participation in EQA, regardless of performance, or may be granted based on meeting minimum levels of performance. In either case, the EQA programme provider should predefine minimum levels of participation or performance and communicate these requirements to the participating laboratories. 42 6 Monitoring laboratory performance, feedback and education Performance monitoring involves setting standards of acceptable performance and identifying participating laboratories that fail to reach these standards. The EQA programme’s objective in identifying unsatisfactory performance is to offer advice and support to assist these laboratories in improving their performance. The need for monitoring of the performance of individual laboratories – and the initiation of appropriate corrective and preventive action in cases of persistent unsatisfactory performance – will be determined by the place of EQA within the existing national quality system. 6.1 SETTING STANDARDS OF ACCEPTABLE PERFORMANCE The first step in performance monitoring is to define standards of satisfactory, unsatisfactory and, possibly, “borderline” performance. The potential clinical significance of errors must be considered when defining standards of acceptable performance. When establishing an EQA programme, it is therefore advisable to operate the programme for a defined period, such as one year, with initial follow-up of errors as described below, but with no formal performance monitoring or scoring. During this time, information can be gathered on current levels of performance within each category of testing, such as rapid or test kit performance for TTI. This process will allow realistically achievable standards of acceptable performance to be set whilst ensuring that major errors, such as a false negative TTI result, are defined as unsatisfactory. For performance monitoring, there should be no differentiation between incorrect results due to technical or procedural errors (such as the incorrect transcription of results or the transposition of exercise materials), although they may be analysed and reported separately. An incorrect result in the blood transfusion laboratory or hospital blood bank can have the same serious consequences, regardless of the reason for the error. For this reason, it is advisable to base performance monitoring – and numerical scoring, if used – on interpretations made rather than on serological reactions recorded for each test. Along with incorrect results, non-return or late return of results also constitutes unsatisfactory performance. Performance standards should be agreed independently by the advisory committee, which includes representatives of participating laboratories M O N I T O R I N G L A B O R A T O R Y P E R F O R M A N C E , F E E D B A C K A N D . . . 43 and experts in the field. The advisory committee should also be responsible for regularly reviewing the definitions of unsatisfactory performance and making changes, where necessary, to reflect improvements in overall performance. 6.2 NUMERICAL SCORING SYSTEMS FOR PERFORMANCE MONITORING Scoring systems can be developed to allow the performance of individual laboratories to be monitored. While such scoring systems can objectively show what progress is being achieved, scoring can have the disadvantage of causing laboratories to collude or “cheat” for fear of obtaining an inadequate score. Such behaviour severely limits the value of EQA programme participation. Therefore it is important for the EQA programme provider to emphasize, to participating laboratory staff, their supervisors and their heads, the importance of non-punitive approaches to EQA performance. A scoring system using penalty points is easiest to weight for clinical significance and to use for the identification of unsatisfactory performance on a cumulative basis. Scoring can be “weighted” to reflect the potential clinical significance of errors made. The scoring system should be determined up front and communicated to participating laboratories as part of the EQA programme information manual. Cumulative scores can be used to identify persistent unsatisfactory performance as well as laboratories with “borderline” performance. Once the system is established, cumulative scores should be given with each exercise report. If this is not possible, cumulative scores can be provided for each laboratory in an annual summary to show trends in individual performance. Examples of numerical scoring systems for performance monitoring are included as Annex 9. 6.3 FOLLOW-UP OF UNSATISFACTORY PERFORMANCE Any follow-up actions by the EQA programme should comply with the procedures laid down by the advisory committee. While it is the role of an EQA programme to perform follow-up actions, the extent of these interventions should be documented and consistent with the resources available to the EQA programme provider. For example, an initial contact could be made by the EQA provider to determine possible causes of error and offer advice. If the EQA programme provider’s interventions yield no subsequent improvement in performance, a letter should be sent to the head of the laboratory to report the situation, formalize the advice that has been offered and suggest possible solutions. Procedures should be put in place to ensure that, once a laboratory becomes an unsatisfactory performer, its progress is then monitored until consistent satisfactory performance is achieved. Programme personnel should be non-judgemental and constructive regarding unsatisfactory performance. Any advice offered should be evidence based and in line with national standards or guidelines, where these exist. 44 S E C T I O N 6 Examples of severe errors include false negative results for any markers or multiple false positive results, failure to identify an intentional clerical error or sample mix-up. Options for ongoing assistance may include:  providing specific, long-term and recurrent advice on improvement opportunities;  providing additional EQA exercise material for troubleshooting;  providing hands-on laboratory training;  facilitating a supervisory visit or audit at the participating laboratory to identify deficiencies, including communication with the laboratory’s head. The programme provider’s ability to undertake these activities will depend on the resources allocated to them. The advisory committee should advocate strongly that these resources be provided, as the benefit of participation in EQA can be maximized only when these support activities are available. On an annual basis, a longitudinal review of performance of participating laboratories should be conducted. This will ensure that any participating laboratory with consistent problems from one EQA exercise to another is followed up adequately. To help monitor the performance of participating laboratories, the EQA programme provider may choose to keep a log of performance of participating laboratories in a logbook or spreadsheet for ease of review. 6.4 SELF-ASSESSMENT In the absence of any performance monitoring or follow-up by the EQA programme, a comparison of an individual laboratory’s results with those obtained by other laboratories is a useful means of highlighting the need for improvement. This process can often raise standards with no intervention from an external source. 6.5 EDUCATION The main purpose of an EQA programme is to improve performance and to provide assistance to address any problems detected. Education should therefore be inherent in all activities of an EQA programme. It can be provided to laboratories on an individual basis as well as to all participating laboratories and other relevant professionals. The programme has a particularly important educational role regarding errors made in EQA exercises by individual participating laboratories. When resources are available, EQA programme personnel can help laboratories identify the root causes of errors and make suggestions for changes in practice and procedures to prevent their recurrence. Errors in EQA exercises may be due to specific technical issues; however, apparently simple errors, such as transcription errors resulting in the recording of an incorrect TTI result, can be indicative of wider problems and deficiencies in a laboratory’s quality system. Education can be provided more widely in the form of reports on the overall performance of different techniques and technologies, which provide specific learning points on best practice. Once a programme is M O N I T O R I N G L A B O R A T O R Y P E R F O R M A N C E , F E E D B A C K A N D . . . 45 well established it may also be possible, with the help of the advisory committee, to organize an annual scientific meeting or a workshop for participating laboratories to address issues highlighted by the EQA exercises. The programme provider should, where possible, communicate information generated by the programme not only to participants but also to a wider audience, by making presentations at local, national and international meetings and through publications. EQA programme data can also be used as a basis for the writing and review of guidelines, making education accessible to all those working in the field of blood transfusion. 46 7 Monitoring and evaluating an EQA programme For an EQA programme to progress, it is important to monitor its development and evaluate its impact on a regular basis. This evaluation will also provide objective evidence in support of the programme’s continuation and be crucial for its sustainability. Evaluation should be undertaken at least once a year and a report produced. 7.1 INDICATORS Process and outcome indicators that could be used to assess the success of a programme are listed below. It should be recognized, however, that an improvement in relation to outcome indicators could be influenced by factors not directly related to participation in an EQA programme, such as the introduction of improved reagents or technology. Process and output indicators Examples of process and output indicators to be collected annually include:  frequency of advisory committee meetings and attendance;  proportion of participating laboratories;  proportion of laboratories returning results for each exercise – late and not at all;  number of laboratories registering for assessment of results on additional tests;  number of problems recorded in relation to the operation of the programme;  number of complaints received and resolved regarding the operation of the programme;  number of times exercise material fails to meet documented requirements;  positive feedback from participants;  troubleshooting and educational activities undertaken;  publications or presentations by the programme. Outcome indicators Examples of outcome indicators include:  proportion of satisfactory and unsatisfactory performance; M O N I T O R I N G A N D E V A L U A T I N G A N E Q A P R O G R A M M E 47  change in overall scores, if applicable;  trends in performance with the same material over several exercises;  improvement or changes in testing used by participating laboratories;  participating laboratories receiving accreditation. 7.2 IMPACT By analysing outcomes, the impacts that the programme has over a period of time can be determined. For example, the proportion of satisfactory versus unsatisfactory performance or the change in overall scores can infer the reduction in erroneous results on donor specimens obtained and therefore the minimization of transmission risk; the improvement in testing practices can be translated into savings in costs and in technologist time. When stakeholders and those providing the funding for the programme learn of these impacts, continued funding of the programme becomes simple to justify. 7.3 ANNUAL REPORT An annual report on the programme should be compiled and distributed to stakeholders, including ministry of health, advisory committee and other interested parties, such as participating laboratories. Its contents may include:  summary of the exercises distributed;  summary of overall performance, highlighting any trends;  summary of process indicators;  learning points from the exercises;  details of developments and challenges within the programme;  overall assessment of the impact of the programme;  human and financial resources, if appropriate and applicable. 48 Glossary This glossary has been prepared using definitions included in ISO 9000:2006, Quality management systems: fundamentals and vocabulary, or ISO 15189:2013, Medical laboratories: requirements for quality and competence. Where definitions were available in these standards, the document reference has been provided. Definitions in italics are intended to define the use of the relevant word or phrases within this document and how the terms relate to each other. Accreditation Procedure by which an authoritative body gives formal recognition that an organization is competent to carry out specific tasks (ISO 15189:2013). Audit Systematic, independent and documented process for obtaining evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled (ISO 9000:2006). Competence Demonstrated ability to apply knowledge and skills (ISO 9000:2006). Competency assessment Process to assess an individual’s ability to apply knowledge and skills. Documentation Written policies, instructions and records involved in providing a product or service. Effectiveness Extent to which planned activities are realized and planned results achieved (ISO 9000:2006). Exercise materials Materials that have been prepared from samples and that make up an EQA panel. External quality assessment (EQA) The external assessment of a laboratory’s performance using exercise materials of known, but undisclosed, content and comparison with the performance of other laboratories. External quality assessment programme A formal programme organized by a recognized institution. This can be a local programme or organized at national, regional or international level. Haemovigilance The monitoring, reporting and investigating of adverse incidents related to all blood transfusion activities. G L O S S A R Y 49 Internal quality control Procedures that verify the attainment of the intended quality of results (ISO 15189:2013). These may include procedures to monitor the day-to-day reproducibility of test results and detect major errors in the analytical process. Management system System to establish a quality policy and quality objectives and to achieve those objectives (ISO 9000:2006). Marker Specific characteristics of exercise materials included in the EQA programme, e.g. HIV antibody, HIV antigen, Treponema antibody. Panel A set of EQA exercise materials. Procedure Specified way to carry out an activity or a process (ISO 9000:2006). Process Set of interrelated or interacting activities that transform inputs into outputs (ISO 9000:2006). Quality The degree to which a set of inherent characteristics fulfils requirements (ISO 9000:2006). Quality management Coordinated activities to direct and control an organization with regard to quality (ISO 9000:2006). Sample A specimen, preferably of large volume, that has been processed, tested, and stored in a sample bank for potential use as exercise material. Specimen Discrete portion of a body fluid, breath, hair or tissue taken for examination, study or analysis of one or more quantities or properties assumed to apply for the whole (ISO 15189:2013). Standard operating procedure Specified way to carry out an activity or a process that is documented, implemented and maintained (ISO 15189:2013). Test Determination of one or more characteristics according to a procedure (ISO 9000:2006). Validation Confirmation through the provision of objective evidence that the requirements for a specific intended use or application have been fulfilled (ISO 9000:2006). Annexes The following annexes are provided for information and as examples on which prospective EQA programme providers may wish to base their documentation and other aspects of the design of their programme, with appropriate local modifications. 1. Preliminary questionnaire for potential participating laboratories 2. EQA registration form 3. Exercise instruction sheet 4. Exercise results form 5. Protocol for homogeneity testing of exercise material 6. Protocol for stability testing of exercise material 7. Record of exercise distributions and returned results 8. Exercise analysis and report 9. Numerical scoring systems 52 Annex 1 Preliminary questionnaire for participating laboratories External quality assessment programme for TTI screening of donated blood Please complete this questionnaire regarding transfusion-transmissible infections screening and general quality measures in your laboratory. Part 1. Contact details Institution name: Contact name: Department: Address: Telephone: Facsimile: Email address: Part 2. Laboratory information 1. Number of staff: 2. Number of specimens processed per year from: Blood donors Others (please specify) 3. Please indicate the TTI screening performed in your laboratory and the test method(s) used Mandatory screening* HIV HCV HBV Syphilis Chagas HTLV I/II Malaria The TTI screened in your laboratory        The TTI for which your laboratory would like an EQA programme        * Screening as mandated by the country A N N E X 1 53 Markers Name of test kits used in your laboratory Name of test kit’s manufacturer Instrument Volume required (mL) include repeat tests and dead volume Test methods used 4. Are independent (not test kit control) internal quality control (IQC) samples included in each test run?  Yes  No If yes, is the performance of these IQCs recorded and monitored over time?  Yes  No 5. Does your laboratory have a microcentrifuge?  Yes  No If yes, what is the minimum and maximum rpm at which it operates? 6. Does your laboratory have a refrigerator?  Yes  No Part 3. EQA scheme preferences How many materials per panel?  1–3  5  10 How many exercises per year?  1  2  3 General comments: 54 Annex 2 EQA registration form Institution name: Contact name: Department: Postal address: Shipping address: Telephone: Facsimile: Email address: Additional contact for receiving report if required Email address: Please indicate the EQA programmes in which your laboratory would like to enrol. Each exercise includes five exercise materials. Participation in two exercises each year is considered the minimum acceptable. Exercise number HIV HCV HBV Syphilis Chagas HTLV I/II Malaria 1        2        3        55 Annex 3 Exercise instruction sheet Intended use This is a coded panel of exercise materials each with known reactivity for: [insert markers included in the panel for assessment]. It is intended to be used for the assessment of the performance of laboratories undertaking routine TTI screening of blood donations. Materials provided  X (insert number) vials of serum exercise materials of Y [insert volume] labelled: 1A, 1B, …  Result sheets Instructions for storage, handling and testing of exercise materials  Vortex, then centrifuge all exercise materials prior to testing.  Process the exercise materials alongside routine donor specimens and in the same way as they would usually be processed by your laboratory.  Warning: The exercise materials are potentially infectious and should be handled using universal safety precautions.  Materials are to be stored at 2–8°C for the duration of the exercise. Instructions for testing of exercise materials  Test the exercise materials in the same way as routine donor specimens would normally be tested, using the testing strategy in use in your laboratory. Instructions for completing the results form  Please tick the relevant box where you have been given a choice of response.  Report only the results of one test kit on each page. Photocopy the relevant page(s) for additional results.  Definitions of abbreviations used in the form: (example) — R: Reactive — N: Negative — INC: Inconclusive Instructions for returning the results  Ensure the return of the results before closing date. 56 Annex 4 Exercise results form Exercise identification code: 01/04 (example) Laboratory registration code: Contact name: Institution name: Telephone number: Email: Date on which your laboratory received the panel: Were the materials received in good condition?  Yes  No Comments: (If panels were received in an unsatisfactory condition, replacement panels can be obtained by contacting the EQA programme provider on the details listed below). The closing date for exercise 01/04 is DD/MM/YYYY Please return completed results forms to [insert EQA provider’s details]: EQA programme provider: EQA contact name: Address: Telephone: Facsimile: Email: A N N E X 4 57 EXERCISE RESULTS FORM: EIA Exercise 01/04 Laboratory registration code: Test kit name: 1st run Operator: Date of testing: Kit lot number: Kit expiry date: 2nd run Operator: Date of testing: Kit lot number: Kit expiry date: Supervisor: Results Exercise material ID S/Co ratio (1st run) S/Co ratios (2nd run) Test kit interpretation OD (A) Cut- off (B) S/Co (A÷B) OD (A) Cut- off (B) S/Co (A÷B) Rep 1 Rep 2 Rep 1 Rep 2 1A  R  N  INC 1B  R  N  INC ...  R  N  INC ...  R  N  INC 1X  R  N  INC Comments: Name of operator reporting results: 58 A N N E X 4 EXERCISE RESULTS FORM: RAPID TEST Programme name / ID: Participant ID: Test kit lot number: Test kit expiry date: Operator initials: Exercise material ID Test date First reader Second reader Final result interpretationc Reader IDa Ab bar / spotb Ag bar / spotb Control bar / spotb Reader IDc Ab bar / spotb Ag bar / spotb Control bar / spotb a Initials. b Neg, Pos, Not Applicable (N/A). c Negative, Reactive, Invalid. 59 Annex 5 Protocol for homogeneity testing of exercise material  Example: Panel composition of exercise panel ID: 01/04 contains 5 exercise materials labelled 1A, 1B, 1C, 1D and 1E.  80 vials of each exercise material were produced and aliquoted during production.  10 representative vials of each EQA exercise material (refer section) are selected for homogeneity testing.  Using a random number generator, record the 10 vial numbers selected for homogeneity testing (e.g. vials 15, 25, 31, 47, 58, 66, 70, 80, 12, 22).  The same vial numbers are to be set aside for each exercise material.  The selected vials need to be renumbered with new homogeneity codes to ensure traceability during testing (e.g. 1A:H1, 1A:H2 ……… 1A:H10, etc.)  Store vials for homogeneity testing at 2–8°C until the testing is performed.  Test each vial once on the appropriate test kit in the same test run.  Any exercise material found to have a result that is different from the reference result must be retested in duplicate. The final test interpretation for this exercise material will be based on the consensus of the three test results. Record results in the appropriate form (see following table).  Before disposal, store the homogeneity vials at 2–8°C until homogeneity results are reviewed and accepted by the EQA programme provider.  Acceptance criteria: An exercise material shall be accepted for inclusion in a panel if all of the test result interpretations for each vial agree with the reference result. 60 A N N E X 5 EXAMPLE: HOMOGENEITY TESTING RESULTS FOR EXERCISE PANEL ID: 01/04 Exercise material: 1A 1B 1C 1D 1E Reference: result Reactive Negative Negative Reactive Reactive H1 Reactive Negative Negative Reactive Reactive H2 Reactive Negative Negative Reactive Reactive H3 Reactive Negative Negative Reactive Reactive H4 Reactive Negative Negative Reactive Reactive H5 Reactive Negative Negative Negative* Reactive H6 Reactive Negative Negative Reactive Reactive H7 Reactive Negative Negative Reactive Reactive H8 Reactive Negative Negative Reactive Reactive Acceptance: Pass Pass Pass Fail* Pass * Repeat testing required in duplicate. The final test interpretation for this exercise material will be based on the consensus of the three test results. 61 Annex 6 Protocol for stability testing of exercise material  Example: Panel composition of exercise panel 01/04 contains 5 exercise materials labelled 1A, 1B, 1C, 1D and 1E.  80 vials of each exercise material were produced and aliquoted during production, which included 6 vials of each exercise material to be selected for stability testing.  The selected vials need to be renumbered with new stability codes to ensure traceability during testing (e.g. 1A:S1, 1A:S2, 1A:S3, 1A:S4, 1A:S5 and 1A:S6).  Identify the time and temperature conditions that the exercise material will be exposed to for the duration of the exercise. EXAMPLE: ACTIVITY AND SCHEDULE FOR EXERCISE PANEL ID: EXERCISE MATERIAL 1A 01/04 Activity Schedule Exercise material Storage temperature conditions Post-production Day 0 2–8°C Start of dispatch Day 4 S1 37°C End of dispatch Day 11 S2 37°C Opening date of exercise Day 12 S3 2–8°C Middle date of exercise Day 25 S4 2–8°C Closing date of exercise Day 32 S5 2–8°C 7-day storage after closing date Day 39 S6 2–8°C  Store stability vials at 2–8°C for 4 days until exercise panels are dispatched to the participating laboratories. Remove stability vial 1A:S1 on day 4, test on the appropriate test kit for the analyte.  Move the remaining 5 stability vials to 37°C ± 1°C and store for 7 days.  Remove stability vial 1A:S2 on day 11, test on the appropriate test kit for the marker.  Move the remaining 4 stability vials and store at 2–8°C. Test the following vials on the appropriate test kit for the analyte as follows: — 1A:S3 on day 18 — 1A:S4 on day 25 — 1A:S5 on day 32 — 1A:S6 on day 39.  Any exercise material found to have a result that is different from the reference result must be retested in duplicate. The final test interpretation for this exercise material will be based on the consensus of the three test results. Record results in the appropriate form (see below). 62 A N N E X 6  Acceptance criteria: Criteria for suitable stability should be based on the effect that instability will have on the uncertainty of the participant’s result, and thereby on the evaluation of the acceptability of a participant’s results. EXAMPLE: STABILITY TESTING RESULTS FOR EXERCISE PANEL ID: 01/04 Exercise material: 1A 1B 1C 1D 1E Reference: result Reactive Negative Negative Reactive Reactive S1 Reactive Negative Negative Reactive Reactive S2 Reactive Negative Negative Reactive Reactive S3 Reactive Negative Negative Reactive Reactive S4 Reactive Negative Negative Reactive Negative* S5 Reactive Negative Negative Reactive Negative* S6 Reactive Negative Negative Reactive Negative* Acceptance: Stable Stable Stable Stable Unstable * Repeat testing required in duplicate. The final test interpretation for this exercise material will be based on the consensus of the three test results. 63 Annex 7 Record of exercise distributions and returned results PANEL ID NUMBER: Laboratory code Documentation packed Materials packed Exercise distributed Results received Comment 0001 0002 0003 0004 0005 0006 0007 0008 0009 0010 0011 0012 0013 0014 0015 0016 0017 0018 0019 0020 0021 0022 0023 0024 64 Annex 8 Exercise analysis and report PRELIMINARY REPORT Material ID* Sample type Comments Anti-HIV-1 status p24 reference result 1 Plasma Negative Negative 2 Pooled plasma Positive Negative 3 Pooled plasma Positive Negative 4 Pooled plasma Negative Negative 5 Pooled plasma Positive Negative 6 Plasma Negative Negative 7 HIV-1 culture supernatant diluted in negative human plasma The sample contains ~5000 pg/mL of subtype B cell culture supernatant Negative Positive 8 Plasma Negative Negative 9 Pooled plasma Positive Negative 10 Plasma Negative Negative * Identification. A N N E X 8 65 CHARACTERIZATION OF THE SAMPLES THAT COMPRISED ANTI-HIV EQA PANEL ID Material ID Murex HIV-1.2.O Ag/Ab EIA (S/Co*) Bio-Rad Genetic Systems HIV- 1 Ag** EIA (S/Co) Bio-Rad Genetic Systems HIV-1 Ag confirmatory HIV-1 western blot Anti HIV-1 status p24 reference result p18 p24 p31 p34 gp41 p53 p68 Test result interpretation 1 0.41 0.20 Not tested Not tested Not applicable Negative Negative 2 14.96 0.24 Not tested – ++ – + ++ ++ +++ Positive Positive Negative 3 15.21 0.21 Not tested – +++ – ++ +++ +++ +++ Positive Positive Negative 4 0.48 0.25 Not tested Not tested Not applicable Negative Negative 5 18.82 0.24 Not tested +++ +++ ++ ++ +++ +++ +++ Positive Positive Negative 6 0.39 0.25 Not tested Not tested Not applicable Negative Negative 7 0.31 40.66 37.83 Not tested Not applicable Negative Positive 8 0.37 0.26 Not tested Not tested Not applicable Negative Negative 9 18.57 0.25 Not tested ++ +++ ++ ++ +++ +++ +++ Positive Positive Negative 10 0.41 0.20 Not tested Not tested Not applicable Negative Negative * Sample: cut-off ratio, where ≥1 is reactive. ** Antigen. 66 A N N E X 8 ANALYSES FOR INCLUSION IN FINAL EXERCISE REPORT Percentage of false negative and false positive results by marker False positive % False negative % Syphilis 0 0 0 0 TND = 100 TPD = 28 HIV 10 9.80 0 0 TND = 102 TPD = 68 Anti-HTLV-I/II 0 0 0 0 TND = 56 TPD = 19 HCV 0 0 0 0 TND = 85 TPD = 26 HBsAg 0 0 2 7.1 TND = 90 TPD = 28 Total 10 2.2 2 1.1 TND = 448 TPD = 175 TND = Total of determinations performed in negative samples. TPD = Total of determinations performed in positive samples. Participants’ performance by marker Participant ID HIV HBsAg Syphilis HCV anti-HTLV-I/II 1 A A A A A 2 A A A A – 3 A A A A A 4 A A A A A 5 A A A A A 6 A A A A A 7 A A A A A 8 A A A A A 9 A A A A – 10 A A A A – 11 B2 A A A A 12 B2 A A A A 13 B2 A A A – 14 A C A A – A = 100% of concordance. B1 = False positive result was reported (≤ 5% of the total of individual participant’s determinations). B2 = False positive result was reported (> 5% of the total of individual participant’s determinations). C = False negative result. – = Not performed A N N E X 8 67 False positive and false negative results (%) reported for each exercise material 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7,69 7,14 4,35% Material ID ANALYSIS BY TEST KIT Example table below shows the number of false results reported for each syphilis test kit used by the participants. Similar tables can be created for the other markers. Test kits FPR % TND FNR % TPD Architect syphilis TP 0 0 30 0 0 9 Murex ICE syphilis 0 0 15 0 0 3 Macrovue RPR card 0 0 10 0 0 2 Trepanostika TP recombinante 0 0 10 0 0 5 Total 0 0 65 0 0 19 TND = Total of determinations performed in negative samples. TPD = Total of determinations performed in positive samples. FPR = False positive results. FNR = False negative results. % FP % FN 68 Annex 9 Numerical scoring systems SIMPLEST SCORING METHOD EVALUATES ONLY THE FINAL STATUS OF EACH MATERIAL WITH TOTAL SCORE OF 100% EQA panel ID Year Score Expected results Positive Negative Negative Positive Positive Material ID 1 2 3 4 5 Participant results Negative Positive Negative Negative Positive 80% SCORING METHOD FOR BOTH TEST RESULT AND FINAL INTERPRETATION EQA panel ID Year Participant results Material ID (expected results) Test kit 1 Test kit 2 Test kit 3 Final status Score 1 (Negative) Non-reactive Not done Not done Negative 2 of 2* or 20 2 (Positive) Reactive Reactive Non-reactive Positive 3 of 4 or 15 3 (Positive) Reactive Reactive Reactive Positive 4 of 4 or 20 4 (Negative) Reactive Non-reactive Non-reactive Inconclusive 2 of 4 or 10 5 (Positive) Reactive Reactive Reactive Positive 4 of 4 or 20 Total score 85% Maximum score = 100 with 20 points allocated to each exercise material. Within each exercise material there are up to four answers required. * Maximum score allocated: both possible answers correct (test kits 2 and 3 did not require answers for material 1). A N N E X 9 69 SCORING METHOD FOR TEST RESULTS, FINAL INTERPRETATION AND FOLLOWING ALGORITHM EQA panel ID Year Participant results Score Material ID (expected results) Test kit 1 Test kit2 Test kit3 Final status Test results (80%) Test algorithm (20%) 1 (Negative) Non-reactive Non-reactive Non-reactive Negative 16/16 0/4* 2 (Positive) Reactive Reactive Non-reactive Positive 12/16 4/4 3 (Positive) Reactive Reactive Reactive Positive 16/16 4/4 4 (Negative) Reactive Non-reactive Non-reactive Inconclusive 8/16 4/4 5 (Positive) Reactive Reactive Reactive Positive 16/16 4/4 Total score 84% Maximum score = 100 points with 20 points allocated to each exercise material. Within each exercise material there are up to four answers required worth 4 points each and 4 points awarded if the algorithm was followed. * No point awarded for following the algorithm because participant continued to test in test kits 2 and 3 despite obtaining a negative result in test kit 1 for material 1. Confidential performance evaluation by marker: External quality assessment scheme – panel ID: Participant ID: Syphilis HIV HTLV HCV HBsAg A A A A A Qualification criteria: A 100% correct results, no false positive and no false negative results. B1 False positive result was reported (≤ 5% of the total of determinations performed by the participant). B2 False positive result was reported (> 5% of the total of determinations performed by the participant). C False negative result was reported.

Guia de implementação Criação de programas de avaliação externa da qualidade na triagem sorológica dos doadores de sangue para detecção de infecções transmitidas por transfusão Criação de programas de avaliação externa da qualidade na triagem sorológica dos doadores de sangue para detecção de infecções transmitidas por transfusão Guia de implementação Catalogação-na-fonte: Biblioteca da OMS: Criação de programas de avaliação externa da qualidade do rastreio das dádivas de sangue para detecção de infecções transmitidas por transfusão: guia de implementação. 1.Transfusão de Sangue – efeitos adversos. 2.Transfusão de Sangue – normas. 3.Transmissão de Doença Infecciosa – prevencão e controle. 4.Seleção do Doador. I.Organização Mundial da Saúde. ISBN 978 92 4 851043 4 (Classificação NLM: WB 356) © Organização Mundial da Saúde 2016 Todos os direitos reservados. As publicações da Organização Mundial da Saúde estão disponíveis no sitio web da OMS (www.who.int) ou podem ser compradas a Publicações da OMS, Organização Mundial da Saúde, 20 Avenue Appia, 1211 Genebra 27, Suíça (Tel: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorder@who.int). Os pedidos de autorização para reproduzir ou traduzir as publicações da OMS – seja para venda ou para distribuição sem fins comerciais - devem ser endereçados a Publicações da OMS através do sitio web da OMS (http://www. who.int/about/licensing/copyright_form/en/index.html). As denominações utilizadas nesta publicação e a apresentação do material nela contido não significam, por parte da Organização Mundial da Saúde, nenhum julgamento sobre o estatuto jurídico ou as autoridades de qualquer país, território, cidade ou zona, nem tampouco sobre a demarcação das suas fronteiras ou limites. As linhas ponteadas nos mapas representam de modo aproximativo fronteiras sobre as quais pode não existir ainda acordo total. A menção de determinadas companhias ou do nome comercial de certos produtos não implica que a Organização Mundial da Saúde os aprove ou recomende, dando-lhes preferência a outros análogos não mencionados. Salvo erros ou omissões, uma letra maiúscula inicial indica que se trata dum produto de marca registado. A OMS tomou todas as precauções razoáveis para verificar a informação contida nesta publicação. No entanto, o material publicado é distribuído sem nenhum tipo de garantia, nem expressa nem implícita. A responsabilidade pela interpretação e utilização deste material recai sobre o leitor. Em nenhum caso se poderá responsabilizar a OMS por qualquer prejuízo resultante da sua utilização. Printed in France. Índice AGRADECIMENTOS INTRODUÇÃO 1 1. AVALIAÇÃO EXTERNA DA QUALIDADE 3 1.1 AEQ como parte de um sistema de qualidade na triagem sorológica dos doadores de sangue para ITT 4 1.2 Avaliação 4 1.3 Avaliação externa da qualidade 5 1.4 Objetivos e benefícios da AEQ 5 1.5 Programas de AEQ 6 2. CRIAÇÃO DE PROGRAMAS DE AEQ PARA O RASTREIO DE ITT 9 2.1 Instituição organizadora 9 2.2 Comissão consultiva 12 2.3 Apoio técnico e administrativo 13 2.4 Sistema de gestão da informação 13 2.5 Finanças 14 2.6 Sistema de qualidade do programa de AEQ 16 2.7 Laboratórios participantes 17 2.8 Estudo-piloto 17 2.9 Passos práticos para a criação de um programa de AEQ 18 3. LABORATÓRIOS PARTICIPANTES 20 3.1 Manual de informação sobre o programa de AEQ 20 3.2 Regras de participação 21 3.3 Registo 22 4. CONSIDERAÇÕES PRÁTICAS PARA A CRIAÇÃO DE UM PROGRAMA DE AEQ 24 4.1 Âmbito 24 4.2 Formato dos exercícios do programa de AEQ 24 4.3 Objetivos do programa de AEQ 25 4.4 Fontes do material dos exercícios 25 4.5 Banco de amostras 27 4.6 Processamento do material de exercício candidato 27 4.7 Documentação dos exercícios 32 4.8 Logística 34 5. PLANEJAMENTO E FUNCIONAMENTO DE UM PROGRAMA DE AEQ PARA TESTES DE ITT 35 5.1 Elaboração de um plano anual de programa de AEQ 35 5.2 Elaboração do plano para um exercício específico de AEQ 36 5.3 Selecção de material para os exercícios de AEQ 36 5.4 Preparação dos materiais dos exercícios 37 5.5 Distribuição do material dos exercícios 38 5.6 Verificação da homogeneidade e estabilidade 39 5.7 Verificação da estabilidade 39 5.8 Embalagem e expedição 40 5.9 Recebimento e prazo para os resultados da AEQ 41 5.10 Compilação dos resultados da AEQ 41 5.11 Análise dos resultados da AEQ 42 5.12 Análise estatística dos resultados de um exercício de AEQ 43 5.13 Elaboração dos relatórios de AEQ 43 5.14 Relatório preliminar 44 5.15 Relatório final 44 5.16 Certificados de participação 45 6. MONITORIZAÇÃO DO DESEMPENHO DOS LABORATÓRIOS, FEEDBACK E EDUCAÇÃO 46 6.1 Definição de normas para um desempenho aceitável 46 6.2 Sistemas numéricos de pontuação para a monitorização do desempenho 47 6.3 Seguimento do desempenho insatisfatório 47 6.4 Auto-avaliação 48 6.5 Educação 48 7. MONITORIZAÇÃO E AVALIAÇÃO DE UM PROGRAMA DE AEQ 50 7.1 Indicadores 50 7.2 Impacto 51 7.3 Relatório anual 51 GLOSSÁRIO 52 ANEXOS 55 1. Questionário preliminar para potenciais laboratórios participantes 56 2. Formulário de registo da AEQ 59 3. Fichas de instruções para os exercícios 60 4. Formulário para os resultados dos exercícios 61 5. Protocolo para o teste de homogeneidade do material dos exercícios 64 6. Protocolo para o teste de estabilidade do material dos exercícios 66 7. Registo das distribuições dos exercícios e resultados recebidos 68 8. Análise e relatórios dos exercícios 69 9. Sistemas numéricos de pontuação 73 Agradecimentos O Programa de Segurança das Transfusões de Sangue do Departamento da OMS para a Prestação e Segurança dos Serviços deseja expressar os seus agradecimentos aos peritos que contribuíram para a elaboração destas orientações para a avaliação externa da qualidade do rastreio de infecções transmitidas por transfusão. Autores Ms Susan Best e colegas National Serology Reference Laboratory Melbourne, Australia Os autores agradecem igualmente às seguintes individualidades, que prepararam a publicação da OMS “Avaliação Externa da Qualidade nas práticas laboratoriais de transfusão: orientações para a criação de um sistema de AEQ na sorologia de grupos sanguíneos” (WHO/EHT/04.09), que a presente publicação pretende complementar. Ms Jenny White, Deputy Scheme Manager NAEQS for Blood Transfusion Laboratory Practice Watford, United Kingdom Mr Robin Knight, Red Cell Immunohematology Service Development Manager National Blood Service, North London Blood Centre, United Kingdom Equipa editorial e colaboradores Dr. Wilai Chalermchan, Senior Laboratory Advisor (contractor), Thailand MOPH - U.S. CDC Collaboration (TUC) Dr.ª Marcia Mitiko Otani, Chefe Depto Controle de Qualidade Serologia, Fundação Pró-Sangue Hemocentro de São Paulo, Brasil Dr. Neelam Dhingra, Coordinator, Patient Safety and Quality Improvement, Service Delivery and Safety, WHO Dr. Noryati Abu Amin, Medical Officer, Blood & Transfusion Safety, Service Organization and Clinical Interventions Unit, Service Delivery and Safety Department, WHO Sr. Junping Yu, Technical Officer, Blood & Transfusion Safety, Service Organization and Clinical Interventions Unit, Service Delivery and Safety Department, WHO Leitores críticos Dr. Alan Kitchen, Head of National Transfusion Microbiology Reference Laboratory, NHS Blood and Transplant, United Kingdom Dr.ª Jane Carter, Amref Health Africa, Wilson Airport, Langata Road, Nairobi, Kenya Dr. Vengetassen (Ravi) Reddy, Chief Operations Officer, South African National Blood Service Dr.ª Vivienne James, Northern Sydney Central Coast Health, Australia Dr. Xun Wang, Head of Transfusion-Transmitted Disease Laboratory, Shanghai Blood Centre, China Dr. Panadda Silva, Director/Expert at Department of Medical Sciences, Ministry of Health, Thailand A presente publicação foi coordenada pelo Dr. Noryati Abu Amin e Sr. Junping Yu. A orientação geral foi prestada pelo Coordenador da Unidade de Melhoria da Qualidade e Segurança dos Doentes, Dr. Neelam Dhingra e pelo Coordenador das Equipas de Organização dos Serviços e Intervenções Clínicas, Dr. Hernan Montenegro. A elaboração desta publicação foi apoiada pelo Acordo de Cooperação Número GH001180, dos Centros dos Estados Unidos para o Controlo e Prevenção das Doenças (CDC). O seu conteúdo é da exclusiva responsabilidade dos autores e não representa necessariamente o parecer oficial dos CDC. 1Introdução A avaliação externa da qualidade (AEQ) é uma componente importante dos sistemas de qualidade dos serviços de transfusão de sangue. A AEQ é a avaliação externa do desempenho geral dos laboratórios na testagem de material de exercício de conteúdo conhecido mas não revelado e em comparação com o desempenho de outros laboratórios que usaram o mesmo material. Nos laboratórios que fazem a triagem sorológica dos doadores de sangue para detectar infecções transmitidas por transfusão (ITT), a participação na AEQ ajuda a monitorizar e a elevar os padrões de desempenho. A informação gerada pela AEQ constitui uma oportunidade para a melhoria contínua da qualidade, através da evidência de erros laboratoriais, e implementar medidas destinadas a evitar a sua recorrência. Assim, a AEQ desempenha um papel importante no reforço da segurança do sangue. A Organização Mundial da Saúde (OMS) desempenha um importante papel de advocacia na promoção da criação de programas nacionais de AEQ e encoraja a participação dos laboratórios de rastreio de ITT nesses programas. As autoridades sanitárias nacionais são instadas a reconhecer a importância da AEQ e a apoiar a implementação desses programas através de uma rede nacional de rastreio de ITT. Os organismos profissionais são encorajados a aprovar e apoiar a criação de programas de AEQ. O documento “Criação de programas de avaliação externa da qualidade no processo de triagem sorológica dos doadores de sangue para detectar infecções transmitidas por transfusão: guia de implementação” pretende apoiar os Estados-Membros da OMS na criação e aplicação de programas de AEQ na triagem sorológica dos doadores de sangue para detectar ITT. O guia foi concebido para ser usado pelas autoridades sanitárias nacionais e pelas instituições organizadoras de AEQ na elaboração de programas de AEQ que possam ser implementados a nível nacional, estatal, provincial e distrital, oferecendo também aos laboratórios participantes uma perspectiva sobre a organização de programas de AEQ para o rastreio de ITT e uma visão geral sobre os benefícios da sua participação. Este guia destina-se a complementar a publicação da OMS sobre “Avaliação externa da qualidade das práticas laboratoriais de transfusão: orientações para a criação de um sistema de AEQ na serologia de grupos sanguíneos” (WHO/EHT/04.09). Por isso, grande parte deste guia reflete a informação incluída na publicação anterior citada. Isso deve-se ao facto de 2I N T R O D U Ç Ã O 1 Triagem sorológica dos doadores de sangue para detectar infecções transmissíveis pelas transfusões: recomendações. Genebra: Organização Mundial da Saúde 2010. os princípios gerais de avaliação externa da qualidade serem os mesmos, independentemente da disciplina. O âmbito das orientações aqui descritas inclui o rastreio serológico obrigatório de todas as dádivas de sangue para detecção do VIH, hepatite B e C e sífilis. O guia pode também ser usado para orientar a implementação da AEQ para outros agentes em relação aos quais é exigido o rastreio obrigatório, num determinado país ou região1. Embora o rastreio para o VIH, hepatite B e C usando teste do ácido nucleico seja efetuado em alguns Estados-Membros, a criação de um programa de AEQ para testes de ácido nucleico está fora do âmbito deste guia, pois seriam necessárias abordagens diferentes para a aquisição, caracterização e análise das amostras, outras infraestruturas e condições logísticas distintas. Este guia destina-se a apoiar a criação de programas de AEQ por instituições organizadoras que se encontrem em diferentes etapas de desenvolvimento. Se não for possível implementar inicialmente todos os elementos aqui descritos, poderá considerar-se uma abordagem por etapas. Mesmo a criação de um pequeno programa básico pode ter um impacto significativo na melhoria contínua da qualidade dos resultados emitidos pelos laboratórios participantes. Ao criar um programa de AEQ do rastreio de ITT, deve incluir-se, em primeiro lugar, a avaliação dos testes obrigatórios estabelecidos no determinado país ou região. O guia descreve os princípios para a criação e funcionamento de um programa de AEQ do rastreio de ITT. Os programas de AEQ devem ser organizados de acordo com esses princípios, embora se devam considerar igualmente aos mecanismos do sistema regulador e de qualidade que possam existir num país para os laboratórios que efetuam o rastreio de ITT. 31 Avaliação externa da qualidade A transfusão de sangue e produtos do sangue seguros e compatíveis envolve vários processos. Em cada processo existe o risco de erro; na seleção dos dadores, na colheita, no processamento e análise das dádivas, na análise das amostras dos potenciais receptores das transfusões e na questão da compatibilidade do sangue e sua administração aos receptores. O laboratório desempenha um importante papel na cadeia da transfusão e eventuais falhas no sistema de qualidade do rastreio das dádivas para detecção de ITT podem ter graves implicações para os receptores do sangue e dos produtos do sangue. Os programas de hemovigilância, tais como o programa sobre Perigos Graves das Transfusões (SHOT), do Reino Unido, revelaram que os erros laboratoriais podem provocar elevado grau de morbilidade e mortalidade nos receptores das transfusões. Os erros laboratoriais podem dever-se a várias deficiências, incluindo:  Procedimentos inadequados na identificação das amostras dos dadores  Armazenamento inapropriado ou uso incorreto de reagentes  Manutenção preventiva e corretiva inadequada dos equipamentos  Práticas erradas dos testes  Inexatidão no registo ou transcrição  Práticas de aquisição de consumíveis inadequadas  Formação inadequada do pessoal  Monitorização inadequada da temperatura ambiente e dos equipamentos  Uso da água de qualidade não apropriada. Os erros resultam, frequentemente, de uma combinação de fatores, sendo o primeiro erro agravado por procedimentos inadequados de verificação nos laboratórios. A finalidade de rastrear dádivas de sangue para detectar ITT é obter sangue e produtos do sangue seguros para transfusão. A implementação de um sistema de qualidade no laboratório de rastreio de ITT procura assegurar que essa finalidade é conseguida através da minimização dos erros. Um rastreio rigoroso de ITT é essencial para obter sangue e produtos do sangue seguros. Além da aplicação de um teste, é igualmente 4S E Ç Ã O 1 importante que os resultados sejam transcritos, reunidos e interpretados corretamente, para oferecer produtos do sangue seguros para transfusão. 1.1 AEQ COMO COMPONENTE INTEGRANTE DE UM SISTEMA DE QUALIDADE NA TRIAGEM SOROLÓGICA DOS DOADORES DE SANGUE PARA ITT A participação na avaliação externa da qualidade deve ser considerada como componente integrante da monitorização do sistema de qualidade geral no laboratório em que o rastreio de ITT é executado. As autoridades nacionais devem definir as diretrizes que os sistemas de qualidade dos laboratórios deverão seguir. Essas diretrizes podem ser estabelecidas a nível nacional, com base nos padrões internacionais, ou podem aplicar-se os padrões internacionais relevantes. Os principais elementos de um sistema de qualidade são:  gestão organizacional, incluindo: — política e plano de qualidade — clara estrutura organizacional — pessoa(s) designada(s) com responsabilidade para criar e gerir o sistema de qualidade — descrição de cargos e tarefas dos recursos humanos;  documentação rigorosa e completa, incluindo procedimentos operacionais padrão e um sistema funcional de controle dos documentos;  formação, tutoria e desenvolvimento profissional contínuo dos recursos humanos;  validação, manutenção e calibração dos equipamentos;  validação de reagentes, dos consumíveis, das técnicas e, quando aplicável, do software;  qualificação de fornecedores;  avaliação, incluindo: — controle interno da qualidade; — auditoria interna e externa; — avaliação externa da qualidade. 1.2 AVALIAÇÃO A melhoria continua da qualidade requer uma monitorização constante e a análise da eficácia de todos os elementos do sistema de qualidade, usando mecanismos internos e externos, para garantir que os padrões de qualidade definidos serão sempre cumpridos. A avaliação interna do sistema de qualidade nos laboratórios inclui:  validação integral de todas as atividades, processos, procedimentos, equipamentos, reagentes e software, antes da sua introdução e utilização;  monitorização regular de todas as atividades críticas, onde a medição contínua dos resultados seja possível e apropriada.  uso de medidas de controle específicas, tais como amostras de controle de qualidade, para monitorizar o desempenho das atividades críticas; Documentação: Políticas, instruções e registos escritos envolvidos na prestação de um produto ou serviço. Procedimentos operacionais padrão: Forma especificada para executar uma atividade ou um processo que está documentado, implementado e mantido – ISO 9000:2006 Controlo interno da qualidade: Procedimentos que verificam a obtenção de resultados de qualidade – ISO 15189:2013. Podem incluir procedimentos para monitorizar a reprodutibilidade diária dos resultados dos testes e detectar os principais erros no processo analítico. Auditoria: processo sistemático, independente e documentado para obter evidências e avaliá-las objetivamente, de modo a determinar até que ponto os critérios das auditorias são cumpridos – ISO 9000:2006. Eficácia: Medida da extensão em que as atividades planeadas são realizadas e os resultados planeados conseguidos – ISO 9000:2006. Validação: Confirmação e apresentação de evidências objetivas de que os requisitos de uma utilização ou aplicação para um uso específico pretendido foram cumpridos –ISO 9000:2006. Avaliação de competências: processo para avaliar a capacidade de um indivíduo para aplicar conhecimentos e competências. A V A L I A Ç Ã O E X T E R N A D A Q U A L I D A D E 5  avaliação da competência dos recursos humanos;  criação de um sistema interno de auditoria, usando padrões relevantes ou outros requisitos de regulação e licenciamento;  criação de um sistema de notificação, investigaç participatingsultadosras ar visdes laboratão e análise dos erros, com medidas eficazes de correção e prevenção. A avaliação externa do sistema de qualidade nos laboratórios inclui:  participação num programa apropriado de AEQ;  auditoria externa por um órgão independente reconhecido. 1.3 AVALIAÇÃO EXTERNA DA QUALIDADE A participação em programas de AEQ é um de vários mecanismos eficazes de identificação das deficiências ou de oportunidades para melhoria dentro dos processos de um laboratório e oferece periodicamente uma visão objetiva do desempenho em relação a outros laboratórios. Outros mecanismos de AEQ incluem a monitorização através de visitas de supervisão ou auditorias, ou programas de troca de amostras. Neste último caso, os materiais são trocados entre os laboratórios e testados de forma codificada. Os resultados são analisados para determinar se todos os laboratórios participantes na troca de amostras obtêm os mesmos resultados. A participação na AEQ envolve testar conjuntos de materiais de exercício de conteúdo conhecido, mas não revelado, que são enviados aos laboratórios participantes pelo operador do programa de AEQ. Cada laboratório participante recebe um conjunto idêntico de materiais de exercício, que deve ser processado da mesma forma que as amostras de rotina das dádivas de sangue, para garantir que o desempenho do laboratório na AEQ reflete com rigor o seu desempenho habitual. Uma vez testados os materiais de exercício de AEQ, os laboratórios participantes reenviam os resultados obtidos nos testes para o operador do programa de AEQ. Depois da recolha e análise dos resultados, cada laboratório recebe feedback sobre os seus próprios resultados, juntamente com os resultados anónimos de todos os outros laboratórios participantes, e os resultados de referência, o que lhes permite comparar o seu desempenho com o dos outros participantes. A avaliação do desempenho através da AEQ permite a um laboratório determinar se o seu sistema está a operar corretamente ou se existem deficiências que exijam correção. Por conseguinte, se necessário, poderá proceder-se à implementação de medidas corretivas e preventivas. Assim, a informação gerada pelo programa ajuda a melhorar a qualidade geral do laboratório de ITT e a segurança do sangue e dos produtos do sangue usados nas transfusões. Mesmo que não esteja criado um sistema de qualidade completo, a AEQ pode sempre ser introduzida como parte de um processo de melhoria contínua da qualidade. 1.4 OBJETIVOS E BENEFÍCIOS DA AEQ O objetivo geral da AEQ é avaliar, manter e melhorar, conforme necessário, os padrões de desempenho dos laboratórios. O apoio para a adopção 6S E Ç Ã O 1 nacional da AEQ pode ser obtido através da sensibilização para a necessidade de aperfeiçoamento, demonstrando os benefícios das melhores práticas e fornecendo informação, educação e apoio para se proceder a essa melhoria. Benefícios para os laboratórios participantes Os benefícios da AEQ para os laboratórios participantes incluem:  identificação das oportunidades para melhorias relacionadas com os processos laboratoriais;  comparação do desempenho de um laboratório com o de outros laboratórios participantes;  comparação do desempenho entre diferentes sistemas de testagem;  prestação de informação e educação, para melhorar o desempenho;  encorajamento do uso das melhores práticas;  oportunidades para melhorar a credibilidade dos laboratórios e aumentar a confiança do público;  acesso a uma rede de laboratórios para troca de informações. Benefícios para a saúde e autoridades reguladoras Os benefícios da AEQ para a medicina transfusional e as autoridades reguladoras incluem:  criação de uma rede de laboratórios do rastreio de ITT com um padrão de desempenho conhecido;  formação e educação dos recursos humanos do laboratório;  prestação de informação útil para ajudar a:  estabelecer padrões  rever as estratégias de testagem  fazer a vigilância pós-introdução no mercado dos kits, lotes, reagentes, novas plataformas e metodologias  uso eficaz dos recursos  melhorar a confiança do público no serviço de transfusão de sangue  apoiar os sistemas de acreditação. A AEQ é mais eficaz na melhoria contínua dos padrões de desempenho, quando se reconhece a necessidade de qualidade. Isso deve contar com o compromisso dos quadros superiores em apoiarem as mudanças necessárias para melhorar o desempenho. A participação na AEQ pode ser um meio eficaz de promover a qualidade em situações em que não existem sistemas de qualidade instalados. Os resultados da AEQ podem revelar um mau desempenho individual e/ou geral e ajudar a identificar a necessidade de normas, orientações, educação e formação, assim como os recursos necessários para os apoiar. 1.5 PROGRAMAS DE AEQ A AEQ deve ser organizada como um programa formal e estruturado para assegurar um planeamento e organização eficazes. Isso garantirá um Acreditação: procedimento através do qual uma autoridade expressa o reconhecimento formal de que uma organização é competente para desempenhar determinadas tarefas – ISO 15189:2013 A V A L I A Ç Ã O E X T E R N A D A Q U A L I D A D E 7 fornecimento assíduo e uniforme de materiais de exercício para testes e uma abordagem normalizada, tanto à análise como à notificação dos resultados e à monitorização do desempenho dos laboratórios participantes. Se for possível, para que a instituição organizadora da AEQ seja acreditada ou cumpra os princípios da ISO/IEC 17043:2010, Avaliação da conformidade: requisitos gerais para os testes de proficiência, isso ajudará a atingir o nível de padrão necessário. A AEQ deve ser disponibilizada a todos os laboratórios que realizam o rastreio de ITT, independentemente da sua dimensão, volume de trabalho ou complexidade dos testes realizados. Os laboratórios podem participar na AEQ, em regime voluntário ou obrigatório, consoante aos sistemas políticos e reguladores instalados. Quando a participação for voluntária, os laboratórios devem ser ativamente encorajados a solicitar AEQ para todos os testes que realizem regularmente. A Figura 1 mostra um modelo de uma rede de programas de AEQ desenvolvida aos níveis internacional, regional e nacional. Em cada nível, o programa fornece os materiais de exercício da AEQ, aconselhamento e apoio aos seus laboratórios participantes e, por sua vez, terá o seu próprio desempenho monitorizado através da participação em outro programa de AEQ. No entanto, neste modelo, o princípio de que as instituições organizadoras de AEQ devem submeter a avaliação o seu próprio desempenho continua a ser de extrema importância. Fig. 1 Rede de esquemas de AEQ Serviços de transfusão de sangue Cidade / Estado / Província / Distrito Regional Internacional Nacional Bancos de sangue dos hospitais Outros laboratórios Internacional Com base nas necessidades dos países, a OMS defende a criação de programas de AEQ aos níveis regional, nacional ou provincial, com a finalidade de facilitar a participação de todos os laboratórios que façam a triagem sorológica dos doadores de sangue para ITT, independentemente do tipo de instituição com que estejam associados. 8S E Ç Ã O 1 Na criação de um programa de AEQ, poderá ser útil procurar informação e apoio junto da OMS ou outros programas bem organizados de AEQ. A nível nacional é aconselhável investigar os programas existentes de AEQ em outras áreas de patologias e a possibilidade de compartilhar as infraestruturas organizacionais, as instalações e os recursos. 92 Criação de programas de AEQ para o rastreio de ITT A criação de um programa de AEQ pode ser da iniciativa da autoridade sanitária nacional, serviço de transfusão de sangue, órgão profissional ou pessoas interessadas. É preciso identificar uma instituição organizadora e determinar a equipa para gerir e operar o programa. Deverá ser constituída uma comissão consultiva para supervisionar a criação do programa e fornecer orientações sobre planejamento e organização. Um programa eficaz de AEQ exige o empenho e o apoio da autoridade ou autoridades sanitárias nacionais, organismos profissionais, instituição organizadora e dos respectivos recursos humanos, fornecedor de material para o exercício da AEQ, logística para transporte do material para o exercício e laboratórios participantes. O êxito do programa depende da confiança, cooperação e eficiência de todas as partes envolvidas. Em particular, o envolvimento dos laboratórios participantes é vital para a organização do programa. As funções, responsabilidades e atividades de todas as partes envolvidas devem ser claramente definidas, para garantir o funcionamento eficiente e eficaz do programa. 2.1 INSTITUIÇÃO ORGANIZADORA A instituição organizadora deve ser uma instituição com instalações adequadas e peritos na área relevante. Idealmente, a instituição deverá ser designada pelo ministério da saúde e ter acesso a fundos atribuídos especificamente para o funcionamento do programa de AEQ, de modo a garantir a independência e a sustentabilidade do programa. A organização e gestão de um programa de AEQ exige grande disponibilidade de tempo, que deve ser devidamente reconhecida, e dotada de recursos para que o programa seja bem sucedido. Para evitar conflitos de interesses, uma organização com interesses comerciais no fornecimento de equipamento ou reagentes de laboratório não deve ser designada como instituição organizadora. A criação de um programa de AEQ constitui uma oportunidade para a instituição organizadora participar numa rede de laboratórios para troca de informações; isso pode também trazer reconhecimento à instituição. A instituição organizadora deverá participar num programa de AEQ internacional ou regionalmente reconhecido na área relevante. Deverá ser capaz de demonstrar um desempenho satisfatório e também mostrar que 10 S E Ç Ã O 2 tem instalado um sistema de qualidade eficaz. A instituição organizadora deve procurar a sua acreditação internacional pelo ISO 17043:2010: Avaliação da conformidade: requisitos gerais para os testes de proficiência. As instalações e os recursos necessários para implementar um programa de AEQ incluem:  espaço;  kits de testes de distintos fabricantes e metodologias;  acesso a testes complementares ou de confirmação;  equipamento;  sistema de purificação de água adequada;  recursos humanos;  apoio técnico;  apoio administrativo;  apoio diretivo;  fonte fidedigna da matéria prima para a confecção do material de exercício;  sistema de gestão da informação;  financiamento adequado. De preferência, as instalações e os recursos necessários serão fornecidos pela instituição organizadora. Contudo, é importante evitar comprometer a qualidade do programa, tentando obter todos os recursos numa só instituição, se isso não for viável. Se for preciso procurar serviços, tais como apoio logístico, em diferentes instituições, para um programa de AEQ, será necessário um sistema eficaz de coordenação. Dentro da instituição organizadora, deverá haver uma equipe de pessoas devidamente qualificadas, com um líder nomeado (chefe da equipe do programa de AEQ), especialmente dedicada a aplicar o programa de AEQ. (Doravante, esta equipe de pessoas será designada de operador do programa de AEQ). O operador do programa de AEQ deve ter uma vasta experiência e conhecimento das melhores práticas no rastreio de ITT, assim como estar atendo às metodologias comuns nos diferentes tipos de laboratórios. Conhecimentos aprofundados e uma boa compreensão são fundamentais para assegurar o planeamento de exercícios eficazes, tal como é também uma percepção das possíveis causas de erro e a capacidade para oferecer aconselhamento adequado, quando solicitado. Responsabilidades O chefe de equipe do programa de AEQ é responsável pela gestão geral, a operação e o desenvolvimento contínuo do programa, dentre as quais podemos citar as seguintes atividades: 1. Gestão geral:  identificação do número de profissionais necessários e suas necessidades de formação;  seleção dos recursos humanos e a respectiva atribuição das atividades e o tempo de trabalho;  garantia da fonte de recursos financeiros e gestão;  convocação das reuniões da comissão consultiva; C R I A Ç Ã O D E P R O G R A M A S D E A E Q P A R A O R A S T R E I O D E I T T 11  comunicação com os fornecedores, laboratórios participantes, comissão consultiva, autoridades reguladoras, meios de comunicação social e, se aplicável, autoridades de acreditação;  identificar os laboratórios que realizarão os testes de confirmação ou validarão o material de exercício do programa, se necessário;  garantia da prestação e uso de um sistema de gestão da informação adequado (manual ou informatizado), para que o programa reúna toda a informação pertinente, os resultados emitidos pelos participantes;  implementação, manutenção e auditoria do sistema de qualidade do programa;  preparação dos relatórios anuais;  preparação de demonstrações financeiras anuais, se necessário;  compilação e tratamento das reclamações e tomada de medidas corretivas;  apresentação de dados nas reuniões dos laboratórios participantes e nas conferências;  promoção do programa. 2. Funcionamento do programa:  criação de exercícios e procura de fonte fornecedora de material para os exercícios;  logística para a distribuição dos materiais para os exercícios;  acompanhamento do retorno dos resultados e envio de lembretes;  verificação da introdução de dados, análise dos resultados, atribuição de pontos e preparação de relatórios individuais e relatórios-síntese;  notificação aos laboratórios participantes dos resultados discordantes e aconselhamento sobre melhoria contínua do desempenho;  prestação de aconselhamento sobre resolução de problemas aos laboratórios participantes;  comunicação ao ministério da saúde sobre a remoção da identificação do desempenho laboratorial e quaisquer problemas com implicações sobre as políticas;  monitorização das tendências no desempenho dos laboratórios e dos kits de testes;  atualização constante do endereço, nome do responsável, telefone e e-mail de contato dos laboratórios participantes. 3. Desenvolvimento contínuo do programa:  atualização constante das novas metodologias de testes de ITT nos laboratórios de transfusão;  início e implementação das mudanças necessárias, para garantir a relevância contínua do programa;  exploração de melhores métodos de gestão dos dados e de prestação de informação;  desenvolvimento da função de educação e formação do programa. 12 S E Ç Ã O 2 2.2 COMISSÃO CONSULTIVA Uma comissão consultiva é indispensável para a concepção, planeamento, e implementação e sustentabilidade do programa. A composição da comissão consultiva deve incluir:  o chefe de equipe do programa de AEQ;  peritos selecionados na disciplina relevante;  representantes de: — centro nacional de sangue — laboratórios participantes — organismos profissionais — laboratórios de confirmação, se necessário — autoridades sanitárias e reguladoras. Uma vez criado o programa de AEQ, a comissão consultiva deve continuar a dar orientações para a sua eficaz continuação. Para garantir uma tomada de decisões e uma comunicação eficazes, a composição da comissão deve ser limitada, devendo ser selecionados os membros que participam ativamente. O número e a regularidade das reuniões da comissão consultiva depende da dimensão do programa e da frequência da distribuição dos exercícios, mas serão necessárias, pelo menos, duas reuniões por ano. A comissão deve elaborar planos anuais com antecedência para as finalidades dos exercícios, de modo a facilitar a compra dos consumíveis e contratação de serviços respectivos. Os membros da comissão consultiva devem manter sigilo absoluto às informações sobre o programa, incluindo sobre os exercícios, especialmente se os seus próprios laboratórios participarem no programa. Funções e responsabilidades As funções e responsabilidades da comissão consultiva incluem: 1. Estabelecer políticas sobre:  estratégia e coordenação do programa;  regras de participação;  inclusão de analitos e marcadores na avaliação e o grau de dificuldade do material de exercício;  assegurar a existência de regulamentos para o transporte seguro do material do exercício;  princípios de pontuação e definição de um desempenho não satisfatório;  medidas a tomar em caso de desempenho não insatisfatório;  análise das reclamações;  medidas a tomar para corrigir o material de exercício que foram perdidos ou danificados;  promoção do programa;  papel do programa na educação e formação;  indicar uma fonte de aconselhamento especializado independente para ajudar os laboratórios com desempenho não satisfatório. C R I A Ç Ã O D E P R O G R A M A S D E A E Q P A R A O R A S T R E I O D E I T T 13 2. Fornecer orientações profissionais e específicas sobre questões de funcionamento, incluindo:  planejamento das finalidades de cada exercício;  criação dos algoritmos pelos quais o material de exercício é caracterizado;  criação dos métodos pelos quais os resultados de referência são determinados;  concordância sobre o conteúdo dos relatórios;  análise do desempenho dos laboratórios em cada inquérito;  tratamento de questões específicas;  divulgação dos comentários e sugestões dos laboratórios participantes;  promoção do papel de educação e formação do programa. 2.3 APOIO TÉCNICO E ADMINISTRATIVO É necessário que a equipe tenha o apoio técnico e administrativo, para assegurar o cumprimento do calendário do programa de AEQ. Esse apoio pode ser obtido dentro da instituição organizadora, por novas designações do pessoal existente, nomeação de pessoal devidamente qualificado ou recorrendo a serviços externos. As tarefas técnicas e administrativas incluem:  recebimento e armazenamento da matéria prima;  aquisição de consumíveis;  processamento e caracterização do material ;  testagem do material do exercício, para garantir a sua adequação e documentar os resultados;  distribuição e rotulagem do material de exercício;  embalagem e expedição dos questionários, exercícios e relatórios finais;  organização de mensageiros e serviços postais;  registro e análise dos resultados e demais informações;  envio de faturas aos laboratórios participantes pelas taxas de registo, se aplicável  contratação do serviço de transporte do material biológico. 2.4 SISTEMA DE GESTÃO DA INFORMAÇÃO Os requisitos para o processamento da informação depende da escala e âmbito do programa. É possível operar um programa de AEQ sem qualquer tecnologia da informação, mas o uso de um sistema informatizado torna mais fácil as tarefas essenciais, como a compilação de resultados, e permite uma análise mais complexa dos resultados. É essencial ser capaz de:  criar uma base de dados (manual ou electrónica) da informação dos laboratórios participantes, incluindo a instituição, o nome dos contactos, endereços, códigos confidenciais de registo, testes e resultados a avaliar; 14 S E Ç Ã O 2  preparar a documentação do exercício, incluindo cartas, instruções, formulários de resultados e etiquetas de endereços;  registar os resultados emitidos pelos laboratórios participantes, usando os códigos confidenciais de registo;  realizar análises básicas, incluindo a comparação dos resultados de cada laboratório participante individual com os resultados esperados e a compilação dos resultados gerais;  analisar os resultados dentro de grupos definidos, como os laboratórios que usam uma técnica particular;  elaborar relatórios com os resultados, os resultados individuais de cada laboratório participante e outras análises ou observações gerais. É desejável que seja possível:  reportar os dados em diferentes formatos, tais como histogramas e gráficos de dispersão;  gerar pontuação para a monitorização do desempenho e pontuação cumulativa;  pesquisar a base de dados, usando critérios específicos. O software informático especializado já existe ou poderá vir a ser desenvolvido, mas muitas destas funções também podem ser executadas usando pacotes de software comerciais normalizados. 2.5 FINANÇAS Os recursos financeiros necessários para criar e operar um programa de AEQ devem ser identificados, os custos estimados e a fonte do financiamento estabelecidos. As Quadros 1 e 2 mostram as principais categorias dos custos de capital e exemplos dos serviços e recursos necessários para a criação e funcionamento adequado de um programa de AEQ. As possíveis fontes de financiamento da criação do programa incluem os governos, as autoridades sanitárias, os organismos profissionais, as organizações não governamentais e as organizações que financiam a pesquisa. Uma fonte de financiamento regular será necessária para o funcionamento contínuo e bem sucedido do programa. Um programa de AEQ poderá recuperar todos ou parte dos custos operacionais, cobrando uma taxa aos laboratórios participantes. Embora o pagamento de uma taxa possa levar os laboratórios participantes a valorizarem o programa, o valor dessa taxa deve ser tal que não constitua uma barreira à participação de um laboratório. As autoridades sanitárias devem prover recursos adequados para garantir a sustentabilidade do programa, permitindo que a contribuição dos laboratórios seja viável. É preciso ter cuidado com o eventual envolvimento de empresas comerciais, pois o programa deve ser visto como independente. C R I A Ç Ã O D E P R O G R A M A S D E A E Q P A R A O R A S T R E I O D E I T T 15 Quadro 1. Custos iniciais de capital Categoria Exemplos Alojamento  Compra ou aluguel de instalações ou adaptação de um edifício existente: — escritório — laboratório — armazenamento em câmara frigorífica — serviços de embalagem e distribuição — almoxarifado Pessoal  Recrutamento  Formação inicial, se necessário Equipamento  Laboratório: — sistema de purificação de água — centrifugadora — incubadora — frigorífico — congelador — equipamento específico de metodologias/ plataformas de testes de ITT, e.g., lavador e leitor de microplacas  Processamento e dispensa: — agitador magnético — liofilizador (opcional) — câmara de fluxo laminar — suporte de pinças — bomba — prateleiras  Armazenamento, embalagem e expedição: — câmara frigorífica ou frigorífico — selador térmico  Escritório: — fotocopiadora — telefone  Tecnologia da informação: — computador Estudo-piloto  Matéria-prima e tempo da equipe de AEQ para: — planejamento do estudo — processamento — distribuição e expedição — análise e relatórios Consultoria de TI (opcional)  Concepção de programas informáticos para: — registo — documentação: cartas, convite, guias, outros — análise dos resultados — elaboração de relatórios 16 S E Ç Ã O 2 Categoria Exemplos Alojamento  Aluguer  Manutenção  Despesas gerais Recursos Humanos  Salários e benefícios  Formação e educação  Custos de viagens e conexos  Inscrições em conferências Equipamento  Contratos de manutenção  Substituições e reparação  Aquisições novas Material do exercício  Matéria-prima — Transporte e armazenamento da matéria prima — processamento, incluindo filtração Testes laboratoriais  Reagentes, kits, testes  Consumíveis, e.g., tubos e pipetas Escritório  Telefone  Material de escritório  Consumíveis para impressão, fotocópias, confecção de relatórios, envelopes e etiquetas Tecnologia da informação  Desenvolvimento de software  Apoio da TI  Ligação à Internet  Computadores Dispensa, embalagem e expedição  Frascos  Embalagem  Correio, mensageiros  Serviços de Courier para transporte de material biológico Reuniões  Comissão consultiva  Reunião anual dos participantes  Ações de formação Honorários de consultoria  Técnico de estatística  Desenvolvimento de TI  Especialista em transfusão 2.6 SISTEMA DE QUALIDADE DO PROGRAMA DE AEQ É essencial que o próprio programa de AEQ tenha um bom sistema de qualidade. Os elementos do sistema de qualidade da instituição organizadora poderão ser utilizados para esse fim. No entanto, será necessário implementar um sistema de qualidade específico e eficaz para o programa, com uma política de qualidade que indique o modo de prestar serviços de AEQ para dar resposta às necessidades dos laboratórios participantes. Essa política deve ser incluída no manual de qualidade do programa, com referências a todos os processos e procedimentos do sistema de qualidade, incluindo os específicos do programa de AEQ e os que são comuns à instituição organizadora. Na organização de um programa de AEQ, há muitos processos diferentes envolvidos. Por isso, é importante garantir que os documentos e registos Quadro 2. Custos correntes contínuos C R I A Ç Ã O D E P R O G R A M A S D E A E Q P A R A O R A S T R E I O D E I T T 17 apropriados para cada passo do exercício do programa sejam gerados para identificação. Eles incluem planos de qualidade, procedimentos operacionais padrão, protocolos de produção, fichas de trabalho, listas de verificação, formulários, resultados da caracterização do material de exercício, interpretações dos kits de testes e informação e resultados comunicados pelos laboratórios participantes. Todos os documentos e registos devem ser mantidos em sigilo, guardados em segurança e estar prontamente acessíveis. O operador do programa de AEQ poderá considerar os seguintes mecanismos para demonstrar a qualidade dos processos:  WHO/CLSI/CDC Sistema de gestão da qualidade dos laboratórios: manual  ISO 15189:2012 Laboratórios médicos: requisitos de qualidade e competência  ISO 17043:2010 Avaliação da conformidade: requisitos gerais para os testes de proficiência  ISO 9001:2008 Sistemas de gestão da qualidade: requisitos  ISO 17025:2005 Acreditação dos laboratórios de testes e calibragem  Desempenho contínuo e satisfatório num programa internacional de AEQ apropriado. 2.7 LABORATÓRIOS PARTICIPANTES Ao organizar um programa de AEQ, a comissão consultiva deve definir o perfil dos laboratórios que devem ser encorajados ou obrigados a participar. O programa deve ser ativamente promovido, de modo a encorajar uma participação plena, mas os mecanismos mais eficazes de promoção dependem do facto do programa ser voluntário ou obrigatório. É importante conhecer o número e tipo de laboratórios que pretendem participar, pois isso terá impacto na organização do programa de AEQ. Os potenciais laboratórios participantes devem receber um questionário preliminar para identificar:  os níveis dos recursos humanos  o volume global do trabalho  o conjunto de testes que são realizados rotineiramente  as técnicas e os reagentes utilizados  o sistema de qualidade implementado. Esta informação pode ser usada para garantir um modelo adequado ao formato dos exercícios de AEQ (secção 4), podendo também ser útil para classificar os laboratórios para monitorização do seu desempenho (secção 6). Um exemplo de um questionário preliminar para obter informação geral acerca dos laboratórios participantes está incluído no Anexo 1. 2.8 ESTUDO-PILOTO Deve fazer-se um estudo-piloto para verificar se a estrutura do programa de AEQ, os métodos de operação propostos e a concepção dos exercícios são apropriados. A finalidade de um estudo-piloto é expor problemas 18 S E Ç Ã O 2 logísticos imprevistos e identificar soluções, antes de efetivar a operação do programa e oferecer uma participação formal. Pelo menos, duas distribuições de exercícios-piloto deverão ser enviadas a um número limitado de laboratórios participantes. Esses laboratórios devem ser selecionados para representarem diferentes grupos de participantes, em função da sua distância (localização, complexidade dos laboratórios ou técnicas que utilizam. Os laboratórios participantes devem ser solicitados a comentar quaisquer problemas que tenham encontrado e apresentar sugestões para corrigir e melhorar. Após a conclusão do estudo-piloto, deve fazer-se uma análise dos problemas que surgiram durante o funcionamento do programa e dos comentários dos participantes. Poderão, assim, fazer-se o ajuste à concepção do programa e à estimativa dos custos de funcionamento, se necessário. 2.9 PASSOS PRÁTICOS PARA A CRIAÇÃO DE UM PROGRAMA DE AEQ Na Figura 2, apresenta-se um esboço dos passos práticos a seguir para a criação de um programa de AEQ. Nas secções seguintes, apresenta-se um debate pormenorizado de cada um desses passos. C R I A Ç Ã O D E P R O G R A M A S D E A E Q P A R A O R A S T R E I O D E I T T 19 Figura 2. Passos para a criação de um programa de AEQ Identificar a instituição organizadora Identificar o programa de AEQ criado para aconselhamento e apoio Criar a comissão consultiva Identificar as fonte(s) de financiamento Identificar os potenciais centros participantes Identificar a fonte provedora e guarda do material de exercício Enviar o questionário prévio a todos os potenciais centros participantes Carta de convite Desenhar o formato do exercício, com base na informação prestada Identificar o mecanismo de distribuição Realizar estudo-piloto Desenvolver sistemas para preparar e distribuir os exercícios, tratar os resultados e monitorizar o desempenho Avaliar o estudo-piloto e fazer modificações, se necessário Promover o programa e registar os laboratórios participantes Implementar o programa Monitorizar e avaliar o programa 20 3 Laboratórios participantes Para participarem eficazmente de um programa de AEQ, os laboratórios participantes deverão reconhecer a necessidade de qualidade e o papel da AEQ no seio de um sistema de qualidade do rastreio de ITT nos laboratórios. Compreender os benefícios da AEQ e a forma como o programa funciona encorajará o cumprimento das regras de participação. Isso evidenciará o valor do programa para cada um dos centros participantes e a qualidade geral da informação gerada. Todo os profissionais dos laboratórios participantes deverão ter acesso aos relatórios de AEQ gerados pelo programa. Os problemas identificados deverão ser discutidos abertamente em reuniões regulares e tratados como problemas relacionados com os procedimentos e práticas laboratoriais e não como críticas aos recursos humanos. A análise profunda das causas dos erros reportados na AEQ constitui uma oportunidade para os laboratórios participantes implementarem alterações destinadas a evitar que se cometam erros semelhantes. Uma vez criado o programa e aberto a participação, é necessário um registo formal, para recolher as informações sobre contactos e outra informação essencial sobre os laboratórios participantes e também para lhes fornecer a informação de que precisam para uma participação eficaz. A informação deverá ser fornecida sob a forma de um manual de informação sobre o programa de AEQ. O operador do programa de AEQ poderá também organizar seminários para os potenciais participantes, a fim de lhes explicar o programa. 3.1 MANUAL DE INFORMAÇÃO SOBRE O PROGRAMA DE AEQ Deve elaborar-se um manual de informação para explicar a gestão e o funcionamento do programa e fornecer instruções práticas para a participação. O manual de informação deve ser distribuído com um formulário de registo. O manual de informação deverá incluir:  finalidades do programa de AEQ;  descrição e informações sobre os contactos para o operador do programa de AEQ;  informações sobre a comissão consultiva;  explicação do compromisso necessário por parte dos laboratórios participantes e dos benefícios da participação;  regras de participação; L A B O R A T Ó R I O S P A R T I C I P A N T E S 21  descrição dos exercícios oferecidos;  explicação sobre o sistema de monitorização e pontuação do desempenho;  definição de um desempenho insatisfatório e medidas a serem tomadas. 3.2 REGRAS DE PARTICIPAÇÃO A comissão consultiva deverá estabelecer regras claras para a participação no programa. Essas regras devem definir:  o que se espera dos laboratórios participantes;  o serviço a prestar pelo programa;  o modo como a informação recolhida será usada, incluindo os dados sobre o desempenho. Os laboratórios participantes terão de concordar com as regras definidas no momento do registo. Exemplos de regras de participação são apresentados nas quadro 1 e 2. Para maximizar os benefícios aos laboratórios participantes e garantir a validade dos dados do programa:  Para testar o material de exercício de AEQ, apenas se devem usar as técnicas e tecnologias que são usadas nos algoritmos de rotina.  O material de exercício de AEQ não deve ser testado apenas pelo técnico mais antigo ou experiente.  O material de exercício de AEQ deve ser testado juntamente com amostras de rotina; não deve ser reservado para testes separados.  O material de exercício não deve ser testado mais do que uma vez e os resultados comparados, a não ser que todas as amostras também sejam testadas rotineiramente desta forma.  O material de exercício excedentário pode ser usado para outros fins, tais como treinamento ou avaliação de competências, depois da apresentação dos resultados da AEQ e término do exercício.  Os resultados devem ser recebidos na data-limite especificada para o exercício.  É preciso que haja aceitação dos procedimentos acordados para a monitorização do desempenho e o seguimento de um desempenho não insatisfatório.  Os direitos de autor dos dados do programa deverão ser protegidos, para garantir que não serão publicados ou apresentados fora de contexto; para usar os dados, é preciso pedir autorização ao operador do programa ou à comissão consultiva. Quadro 1. Exemplo de regras para a participação dos laboratórios no programa de AEQ 22 S E Ç Ã O 3 Para garantir o eficaz funcionamento do programa:  A confidencialidade dos dados do desempenho deve ser mantida entre o operador do programa, a comissão consultiva e o laboratório participante, a não ser que exista uma obrigação legal ou por acordo prévio para a sua revelação a uma parte terceira.  O material de exercício fornecido deve ser de qualidade confiável.  Terá de ser estabelecido um calendário claro para a distribuição dos exercícios e a devolução do relatório.  O material de exercício terá de ser seguro.  Os relatórios do programa de AEQ terão de incluir sugestões para melhorar o desempenho.  O organizador da AEQ deve estar disponível para responder às perguntas ou preocupações dos laboratórios participantes.  O material de exercício não deve ser enviado para testes em outro laboratório, nem devem ser estabelecidas comunicações com outro laboratório participante acerca dos resultados. 3.3 REGISTO Referente ao registo, todos os laboratórios interessados deverão receber um formulário próprio, juntamente com o manual de informação. O formulário de registo deve solicitar a seguinte informação:  Contactos para a entrega dos materiais do exercício e relatórios:  Nome do laboratório participante  Nome do responsável pelo laboratório participante  Nome da pessoa que irá receber o material de exercício  Endereço postal completo  Número de telefone  Número de fax  Endereço electrónico, se houver. O nome e endereço de uma outra pessoa como, por exemplo, o chefe do laboratório ou da instituição participante pode também, se necessário, ser fornecido para correspondência relacionada com o desempenho. Os testes de rotina usados pelo laboratório participante, e através dos quais ele pretende ser avaliado, devem ser mencionados, permitindo ao operador do programa identificar os testes para os quais se esperam resultados do exercício de cada laboratório. De preferência, os laboratórios participantes devem ser avaliados por todos os testes que realizam rotineiramente. O formulário de registo deve incluir também uma secção que deve ser assinada pelo laboratório participante, indicando a sua concordância em cumprir as regras de participação. Exemplos de formulários de registo estão incluídos no Anexo 2. A cada laboratório participante deve ser atribuído um código de registo confidencial a usar na correspondência com o programa, para garantir a confidencialidade dos resultados e dos dados do desempenho. Esse Quadro 2. Exemplos de regras para o programa L A B O R A T Ó R I O S P A R T I C I P A N T E S 23 código e a informação contida no formulário de registo de cada laboratório devem ser introduzidos no sistema de gestão da informação do programa. Se for usada uma base de dados informática, cada componente dessas informações (tais como o código de registo e cada linha do endereço) deve ser introduzida em campos separados, para facilitar a pesquisa de dados. A informação sobre os laboratórios participantes deve ser atualizada por um novo registo anual; deve ser distribuído um novo formulário de registo, com uma cópia das informações atualizadas de registo, para confirmação. Isso permitirá ao programa obter informações técnicas e informações de contactos sempre atualizadas. 24 4 Considerações práticas para a criação de um programa de AEQ A informação obtida através de questionários prévios, respondidos pelos potenciais laboratórios participantes, deve ser usada para se elaborarem os exercícios de AEQ. Sempre que possível, cada exercício de AEQ deve ter uma função educativa, explorando áreas onde se sabe que ocorrem grandes variações nos testes ou que se imagina serem desafiadoras para os laboratórios. Durante a concepção do programa, deve ter-se em consideração os seguintes aspectos práticos:  âmbito  o programa de AEQ e o formato dos exercícios  objetivos do programa  fonte e processamento do material de exercício  documentação dos exercícios  análise e comunicação dos resultados. 4.1 ÂMBITO Um exercício de AEQ para as ITT deve responder às necessidades dos laboratórios participantes e avaliar os testes rotineiramente realizados para triagem sorológica dos doadores de sangue. Isso pode ser avaliado através das respostas dos laboratórios ao questionário prévio. O rastreio de marcadores, como os anticorpos HIV-1/2, anticorpos da hepatite C, antigénio de superfície da hepatite B e anticorpos do Treponema pallidum normalmente são realizados de rotina num laboratório de ITT e, portanto, deve ser incluído nos exercícios do programa de AEQ. Conforme o âmbito dos testes dos laboratórios participantes e os estabelecidos como obrigatórios por legislações nacionais para o rastreio de ITT, os marcadores poderão ser ampliados de modo a incluir o antigénio HIV-1 p24, anti-HBc da hepatite B ou outros marcadores como os anticorpos do Trypanosoma cruzi, paludismo e HTLV-I/II. 4.2 FORMATO DOS EXERCÍCIOS DO PROGRAMA DE AEQ O número de exercícios de AEQ a fornecer num ano deve ser suficiente para permitir uma avaliação adequada dos procedimentos e práticas laboratoriais e para recolher dados suficientes para monitorização C O N S I D E R A Ç Õ E S P R Á T I C A S P A R A A C R I A Ç Ã O . . . 25 cumulativa do desempenho. Pelo menos, dois exercícios por ano devem ser distribuídos aos laboratórios participantes, para se obter um nível mínimo de confiança no desempenho dos laboratórios. O número de materiais a incluir num exercício de AEQ deverá permitir a detecção de potenciais erros laboratoriais. Um exercício que consista num pequeno número de materiais (por exemplo, 1–4) poderá detectar erros ocasionais, mas terá limitada capacidade para detectar erros sistemáticos. Os painéis que consistirem num maior número de materiais de exercício (por exemplo, 5–10) terão maior capacidade para detectar erros ocasionais e sistemáticos. 4.3 OBJETIVOS DO PROGRAMA DE AEQ Cada exercício de AEQ deve abordar questões ou objetivos específicos; o painel de AEQ deve ser construído de modo a abordar esses objetivos. Um bom programa de AEQ deverá ensinar aos laboratórios participantes as boas práticas laboratoriais e ser capaz de identificar os diferentes erros que possam ocorrer. Alguns objetivos e mecanismos possíveis são apresentados na Quadro 3. Objetivo Mecanismo O laboratório participante pode identificar corretamente o resultado das amostras? Os resultados do laboratório participante equivalem aos resultados de referência? O laboratório participante segue os protocolos do kit do fabricante? Coletar a informação detalhada dos testes no formulário de resultados, por exemplo, as variações nos controlos do kit de testes e tempo de leitura. O laboratório participante produz resultados consistentes? Incluir réplicas do mesmo material de exercício O laboratório participante produz resultados consistentes ao longo do tempo? Incluir réplicas do material de exercício em diferentes exercícios O laboratório participante tem estabelecido um processo para rejeitar as amostras inadequadas? Incluir material hemolisado ou outro material de exercício inadequado e avaliar se o laboratório participante faz realiza testes do material O laboratório participante consegue identificar erros administrativos? Incluir materiais de exercício que foram intencionalmente mal rotulados erroneamente Comparar o desempenho dos diferentes sistemas de testagem Analisar os resultados, de acordo com os diferentes sistemas e tecnologias Verificar a cobertura do rastreio obrigatório de ITT Incluir todos os marcadores obrigatórios Verificar o relatório do laboratório 4.4 FONTES DO MATERIAL DOS EXERCÍCIOS O material de exercício deverá, de preferência, ser obtido do serviço de transfusão de sangue, visto que o sangue dos dadores é ideal como material de exercício. Está prontamente disponível em grandes volumes e é testado para ITT, de acordo com a regulamentação local. Contudo, Quadro 3. Objetivos e mecanismos do programa de AEQ 26 S E Ç Ã O 4 a ética que preside ao seu uso deve ser esclarecida. Idealmente, deve obter-se o consentimento informado dos dadores, para que se possa usar o seu sangue para fins da AEQ. Poderá ser difícil conseguir o número necessário de dádivas positivas para ITT de doadores. Quando não estiver disponível material de dadores e tiver de ser usado material do paciente infectado, é preciso obter o seu consentimento informado. Os algoritmos do serviço de transfusão de sangue determinam que sejam descartadas as dádivas repetidamente reativas num kit de testes de rastreio de ITT, isto é, os testes de confirmação não se realizam. Nesses casos, a reatividade pode ser verdadeira ou falsa e, se as dádivas forem usadas como material de exercício, a confirmação deverá ser realizada pelo operador do programa de AEQ ou um laboratório especializado designado. Devem fazer-se todos os esforços para assegurar que as dádivas a usar como potencial material de exercício sejam confirmadas como positivas. Isso é importante, em virtude dos custos envolvidos no transporte de embalagens de plasma, de acordo com os regulamentos, e dos testes de confirmação. Esses investimento será desperdiçado, se a reatividade da unidade de plasma não for a esperada. As medidas que o operador do programa pode implementar são:  Considerar a prevalência de ITT na população de dadores dos quais são obtidas as unidades de plasma reativas. Deve dar-se preferência à obtenção de unidades de plasma nos serviços de transfusão de sangue, onde a prevalência de determinada ITT é mais elevada e, por isso, o valor positivo preditivo do resultado recativo no kit de testes de rastreio é mais elevado.  Escolher os fornecedores de “kits” diagnósticos com bons sistemas de qualidade instalados, para que a qualidade dos resultados dos testes possa ser confiável. Os fornecedores de material de exercício devem ser selecionados de acordo com a sua capacidade para fazer um fornecimento fiável da quantidade de material necessária e assegurar a sua qualidade. Deverá estabelecer-se um acordo formal entre o operador do programa de AEQ e o fornecedor ou fornecedores, para assegurar que o fornecimento do material de exercício é fiável e cumpre todas as especificações definidas pelo programa. É essencial que o operador do programa de AEQ ou um perito de laboratório, se tal for o caso, consiga caracterizar o material de exercício com rigor, mesmo que os laboratórios participantes não sejam obrigados a realizar testes exaustivos (ver secção 5.3 sobre a seleção do material de exercício). As amostras candidatas para o material de exercício de ITT podem ser organizadas num “banco de amostras” – um repositório de um vasto número de amostras de grande volume com características diferentes. Isto é possível, porque, no caso das ITT, o material de exercício mais comum é o plasma ou o soro, que podem ser guardados congelados durante longos períodos de tempo, sem comprometer a sua reatividade serológica. São necessários recursos significativos e contínuos para criar e manter um banco de amostras. Materiais de exercício: os materiais que foram preparados a partir de amostras e que constituem um painel de AEQ. Painel: um conjunto de materiais de exercício da AEQ. Amostra: um espécime, preferencialmente de grande volume, que foi processado, testado e guardado num banco de amostras para eventual uso como material de exercício. Espécime: Pequena porção de fluido corporal, sopro, cabelo ou tecido colhido para exame, estudo ou análise de uma ou mais quantidades ou propriedades consideradas como aplicáveis ao todo (ISO 15189:2013). C O N S I D E R A Ç Õ E S P R Á T I C A S P A R A A C R I A Ç Ã O . . . 27 4.5 CRIAÇÃO DE UM BANCO DE AMOSTRAS A criação de um banco de amostras de ITT para o soro e o plasma a usar como material de exercício deve ser iniciada com muita antecedência, em relação ao primeiro exercício do programa de AEQ. O soro e o plasma candidatos, devem ser processados em momento oportuno e adequadamente armazenados. Ao serem recebidos, deve atribuir-se- lhes um número único de identificação laboratorial. Um soro ou plasma candidato obtido em grandes volumes devem ser aliquotados em volumes menores, com o fim de reduzir o número dos ciclos de congelamento/ descongelamento. O soro e o plasma devem ser armazenados congelados a –20°C ou menos, em recipientes de propileno de volume apropriado, com tampas de rosca à prova de vazamento, contendo um vedante, como um anel de borracha. Os recipientes devem ser corretamente rotulados, usando etiquetas adesivas de boa qualidade. O material de exercício deve ser cuidadosamente caracterizado, através de estratégias de teste validadas, para determinar o verdadeiro estado serológico do material, e a informação guardada numa base de dados (ver subsecção sobre caracterização e testes do material de exercício de AEQ, na secção 4.6). Uma base de dados dos bancos de amostras é um inventário do material biológico do repositório. A informação constante do inventário deve ser regularmente atualizada, pois terá de ser consultada todas as vezes que se planeia um exercício de AEQ. O tipo de informação a registar numa base de dados sobre um banco de amostras é a seguinte:  Número de identificação laboratorial único  Número de referência ou código  Dados obtidos  Dados recebidos  Tipo de material (e.g., soro, plasma)  Volumes e número de frascos (se aliquotados em volumes menores)  Informação clínica e resultados dos testes do operador  Resultados dos testes de caracterização  Localização do banco de amostras no congelador  Etiquetas das amostras2  Número de ciclos de congelamento/descongelamento. Uma vez criado o banco de amostras, recomenda-se que seja contínuo o fornecimento de material, para manter o número e os volumes apropriados de materiais de exercício necessários para futuros exercícios de AEQ. 4.6 PROCESSAMENTO DO MATERIAL DE EXERCÍCIO CANDIDATO Apesar do plasma ser um material biológico adequado aos exercícios de AEQ para ITT, há aspectos a considerar quando é usado como material 2 É útil atribuir uma “etiqueta” ou código a cada soro ou plasma, para ajudar a procurar e identificar os materiais na base de dados. 28 S E Ç Ã O 4 3 Ratnoff OD. An accelerating property of plasma for the coagulation of fibrinogen by thrombin, Journal of Clinical Investigation. 1954;33:1175–82. 4 Bobbitt JA, Betts RP. The removal of bacteria from solutions by membrane filtration. Journal of Microbiological Methods. 1992;16(3):215–20. de exercício de AEQ (por exemplo, limitações de volume e formação de coágulos, independentemente de filtração ou fase de centrifugação). Em alguns casos, o plasma desfibrinado ou o soro pode ser considerado como uma alternativa ao plasma. Seja qual for o material biológico a ser usado como material no exercício de AEQ para ITT, deverá considerar-se as necessidades dos laboratórios participantes e a validade do material a usar nos métodos de testes ITT. Pode proceder-se a manipulações para aumentar o volume ou a qualidade dos materiais biológicos usados em exercícios de AEQ. É de sublinhar que os materiais do exercício de AEQ deverão ser tão representativos quanto possível das amostras “originais” dos dadores. Cada manipulação efetuada irá causar um desvio à “normalidade”. Para além disso, uma manipulação pode ter um efeito adverso sobre os resultados produzidos pelos diferentes métodos de teste. Assim, cada método de manipulação deverá ser largamente validado pelo seu efeito, antes de ser aplicado ao material de exercício de AEQ. Conversão de plasma em soro O plasma colhido em sacos de colheita dos dadores deverá conter um anticoagulante, como o citrato-fosfato-dextrose (CPD) e, assim, a conversão em soro não á naturalmente possível. No entanto, o plasma pode ser convertido em plasma desfibrinado (ou seja, em soro), iniciando artificialmente a cascata de coagulação através da adição de trombina, seguida da remoção do coágulo resultante. Uma vez removido o coágulo, deverá proceder-se à microfiltração do soro para remover qualquer contaminação bacteriana3. Filtração Os materiais biológicos podem ser filtrados usando um aparelho de filtração a vácuo ou pressão, numa redução gradual do tamanho dos poros (pré-filtro, 0,8 microns, 0,45 microns e um final 0,22 microns). A filtração irá remover quaisquer micropartículas, desde microcoágulos a contaminação bacteriana4. É preciso ter em conta que a conversão do plasma em soro e os processos de filtração são complicados, trabalhosos e potencialmente perigosos. Por isso, estes processos deverão ser realizados em câmaras de segurança biológica, por técnicos com o adequado equipamento de proteção individual, incluindo batas, luvas e máscaras faciais ou óculos de proteção. Contudo, deverão ser desenvolvidos esforços para fornecer material de exercício sem contaminação, material particulado e coágulos. Sem a conversão do plasma em soro, pode ser produzido material de exercício razoavelmente satisfatório por centrifugação do material, para remover material particulado e coágulos. Para manter a esterilidade sem C O N S I D E R A Ç Õ E S P R Á T I C A S P A R A A C R I A Ç Ã O . . . 29 5 ProClin : http://www.sigmaaldrich.com/content/dam/sigmaaldrich/docs/SAFC/ General_Information/proclin_efficacy.pdf. filtração, o material de exercício deverá ser manuseado numa câmara de biossegurança de classe II, tendo em conta, o mais possível, as técnicas assépticas e usando equipamento e contentores estéreis. Uso de biocidas Pode considerar-se o uso de biocidas para reduzir o potencial de crescimento de microorganismos e preservar a qualidade do material biológico. Um exemplo de biocida é o ProClin 300 (1,5% metilisotiazolinona, metilcloroisotiazolinona). A azida de sódio, que anteriormente foi largamente usada como um biocida, deixou de ser recomendada por questões de segurança. Deverá proceder-se a uma minuciosa validação de qualquer biocida para identificar uma potencial interferência com os métodos de testagem das ITT5. Mistura Em muitos programas de AEQ, a mistura de soros poderá ser considerada uma opção para aumentar o volume do material do exercício disponível (quando o volume necessário para o número de participantes exceder o que normalmente é encontrado numa única dádiva de sangue). A mistura de amostras envolve agregar amostras individuais para criar uma amostra combinada mista. Contudo, da mistura das amostras pode resultar um efeito de diluição – por outras palavras, a diluição dos componentes individuais de cada amostra usada na combinação. Este risco pode ser reduzido através da seleção de amostras com anticorpos ou de perfis de antigénios semelhantes, averiguado por testes, reunindo assim apenas amostras com perfis ou características semelhantes nos resultados testes. A combinação tem o benefício de aumentar o volume do material do exercício, procurando ao mesmo tempo manter a reatividade dos componentes-chave nas amostras que constituem essa combinação mistura. Por vezes, a mistura de soros ou plasmas negativos podem revelar uma maior tendência para uma falsa reatividade. Por isso, os materiais de exercício misturados, sejam negativos ou positivos, deverão ser testados inúmeras vezes antes de serem usados num programa de AEQ. Diluição Sempre que possível, deverá evitar-se a diluição com plasma negativo ou qualquer outro diluente isotónico para produzir os materiais do exercício. A diluição de material biológico para aumentar o volume será viável se o material apenas for diluído até ao ponto necessário para criar o volume adicional. A diluição para imitar perfis de infecções recentes ou resultados “fracos” cria um material de exercício final que não possui um perfil serológico representativo do que se observa em amostras não diluídas dos dadores de sangue. Além disso, pode reduzir-se a capacidade de alguns testes detectarem anticorpos ou antigénios presentes em pequenas concentrações que seriam normalmente detectados se não fossem diluídos. O operador do programa de AEQ deverá testar o material 30 S E Ç Ã O 4 6 Parekh BS, Anyanwu J, Patel H et al. Dried tube specimens: a simple and cost- effective method for preparation of HIV proficiency testing panels and quality control materials for use in resource-limited settings. Journal of Virological Methods. 2010;163(2):295–300. do exercício diluído num grande número de kits de teste destinados a serem usados no programa, para garantir que o seu comportamento será o esperado. A diluição de marcadores quantificáveis – por exemplo, o antigénio de superfície da hepatite B (HBsAg) ou o antigénio HIV-1 p24 – poderá ser considerada como uma opção para produzir material serológico do exercício representativo de uma infecção recente, em que é difícil encontrar material biológico que surja naturalmente em quantidade suficiente. No caso do HBsAg, deverá ter-se cuidado para não sobrediluir outros marcadores precoces da hepatite B (anti-HBc IgM), se esses forem marcadores que o programa de AEQ esteja a avaliar. Além disso, o diluente deverá estar livre do anticorpos de superfície da hepatite B pois é provável que forme um complexo com o HBsAg e o torne não adequado para o sistema de testagem. Amostras liofilizadas As condições de transporte são os principais contribuintes para a baixa qualidade do material do exercício. E somado o fato de que os custos para o transporte de material biológico são elevados, o que aumenta o encargo financeiro ao programa de AEQ. Alguns programas de AEQ para cenários de recursos limitados são fornecidos como amostras liofilizadas (DTS). Trata-se de pequenas quantidades de soro ou plasma positivo ou negativo que foi desidratado ao ar durante 12–24 horas6. Apenas podem ser desidratadas pequenas quantidades durante este período (por exemplo, 20 microlitros), mas os grânulos desidratados são reconstituídos num volume dez vezes superior, normalmente numa solução tampão de fosfatos, o que resulta em material do exercício diluído dez vezes mais e que tem uma matriz diferente das amostras verdadeiras de soro ou plasma. Não é aconselhável o uso de amostras fracamente positivas nos programas DTS de AEQ, dado que a diluição poderá causar reações falsas negativas em todos ou em alguns kits de testes. O operador do programa de AEQ deverá reconstituir e testar as DTS num grande número de kits de teste a usar no programa, de modo a garantir que o material do exercício se comporte como previsto. Apesar destas diferentes abordagens que contrariam as normas convencionais da AEQ, o uso de DTS torna de alguma forma possível a monitorização da qualidade em situações em que os programas de AEQ convencionais não são viáveis. Deve salientar-se que se os DTS são fornecidos como material do exercício para um programa de AEQ, os laboratórios participantes deverão reconstituí-los antes da testagem. Trata-se de uma variável adicional, cujo potencial impacto deverá de ser considerado ao analisar e pontuar os resultados. C O N S I D E R A Ç Õ E S P R Á T I C A S P A R A A C R I A Ç Ã O . . . 31 Caracterização e testagem do material do exercício de AEQ São estes os principais atributos do material do exercício de AEQ para ITT:  que o tipo de amostra seja geralmente aprovado pelos fabricantes dos kits de teste que são usados pelos participantes do programa, por exemplo soro ou plasma;  que o material do exercício seja homogéneo e estável durante o período de execução do exercício;  que o estado real do material do exercício seja conhecido para os marcadores sujeitos a avaliação. As instruções de utilização contidas nos kits de teste para ITT normalmente especificam os tipos de amostra apropriados para usar nos testes. É importante que o material do exercício fornecido no programa de AEQ represente tanto quanto possível um tipo de amostra que seja permitido para todos os testes; caso contrário, podem obter-se resultados aberrantes se o tipo de amostra for significativamente diferente dos recomendados. Por exemplo, como acima se mencionou, amostras liofilizadas reconstituídas com solução tampão fosfato apropriado como um tipo de amostra, que deverá ser confirmada pelo operador do programa em todos os kits de testes usados pelos participantes no programa. A caracterização das amostras é normalmente conseguida realizada através de uma estratégia de teste e de um algoritmo definido. A estratégia do teste define a amplitude e os tipos de testes usados para determinar o estado de uma amostra; um algoritmo especifica os nomes dos testes e a ordem pela qual eles são usados realizados. Uma estratégia de teste inclui um primeiro teste para identificar amostras negativas e um ou mais testes suplementares que são usados para confirmar se essas amostras que são reativas no primeiro teste são ou não positivas. Esta confirmação de reatividade positiva é realizada porque todos os testes para ITT dão uma pequena percentagem de resultados falsos positivos. A testagem num segundo teste ajuda a garantir que as amostras do banco de amostras classificadas como reativas são realmente positivas. O primeiro teste num algoritmo deverá ter uma sensibilidade muito apurada, especialmente porque ele irá identificar amostras negativas, ou seja, um resultado negativo de um primeiro teste será assumido como correto e não se executará mais nenhum teste para “confirmar” o estado negativo do material antes do seu estado ser considerado no banco de amostras. Por essa razão, o operador do programa precisa de ter confiança no primeiro kit de testes usado para caracterizar se a amostra do banco, de que o teste é dos mais sensíveis, disponíveis no mercado. E não irá classificar erradamente as amostras positivas que poderiam ser detectadas por outros kits de teste usados pelos laboratórios participantes no programa de AEQ. O operador do programa de AEQ terá de considerar criteriosamente a forma como as amostras dos bancos de sangue são caracterizadas. Por exemplo, se alguns laboratórios participantes tiverem indicado que usam ensaios combinados do VIH, para detectarem anticorpos do antigénio do VIH e p24, o material do exercício de AEQ deverá ser caracterizado para ambos os marcadores. De modo semelhante, se os laboratórios participantes usarem testes treponemos da sífilis específicos ou não 32 S E Ç Ã O 4 7 http://www.who.int/diagnostics_laboratory/evaluations/en/. específicos, deveria ser conhecido o estado dos materiais do exercício de AEQ para estes dois marcadores. Os principais atributos a considerar ao escolher os testes de caracterização das amostras e ao testar os materiais para o exercício de AEQ são:  Testes disponíveis. A maioria dos países deverão ter uma lista de testes que podem ser comercializados para cada marcador.  Características dos testes. É necessária informação acerca do desempenho dos testes (sensibilidade e especificidade), a sua facilidade de utilização, os requisitos do equipamento e outras características. Essa informação poderá ser encontrada no website da OMS7. Outra fonte de informação são as publicações em revistas especializadas.  Finalidade dos testes. Um operador do programa de AEQ poderá realizar testes para outras finalidades além da caracterização do material AEQ. É esta testagem que irá determinar a escolha dos testes, por exemplo, qual é o rendimento de um teste; qual é o tempo necessário para a realização do teste; qual é o prazo de validade dos reagentes; e se há ou não necessidade de refrigeração. 4.7 DOCUMENTAÇÃO DOS EXERCÍCIOS Cada exercício de AEQ exige documentos de acompanhamento, que poderão incluir:  instruções sobre o modo de manusear, testar e notificar resultados para o material do exercício de AEQ;  formulários dos resultados;  questionário de feedback, incluído periodicamente, de modo a permitir uma melhoria contínua do programa. Os formulários de instruções geradas para cada um dos exercícios deverão fornecer informação geral sobre o modo de manusear, testar e armazenar o material do exercício e de reportar os resultados ao operador do programa de AEQ. Os laboratórios participantes deverão lembrar-se de que o material do exercício deve ser tratado como amostras de rotina e ser sujeito aos mesmos processos e testagem. As fichas de instrução incluem geralmente as seguintes informações:  número e identificadores do material de exercício;  código do exercício;  prazo para envio dos resultados;  instruções de armazenamento e manuseamento;  instruções de testagem;  instruções de notificação;  precauções de segurança biológica; e  informação sobre os contactos do com o operador do programa de AEQ. C O N S I D E R A Ç Õ E S P R Á T I C A S P A R A A C R I A Ç Ã O . . . 33 Apresenta-se no Anexo 3 um exemplo de uma ficha de instruções do exercício. O operador do programa de AEQ deverá preparar um formulário de recebimento dos resultados dos exercícios de AEQ. O formulário dos resultados AEQ poderá ser dispensado eletronicamente ou em papel. Seja qual for o mecanismo usado, esse formulário permitirá uma abordagem normalizada ao recebimento dos resultados dos testes AEQ e à informação dos laboratórios participantes. Um formulário para recebimento de dados em papel requer que o operador do programa de AEQ elabore um formulário a enviar aos laboratórios participantes com o painel do exercício. Após a conclusão do teste do exercício, os laboratórios deverão apresentar os formulários preenchidos com os resultados ao operador do programa de AEQ por e-mail ou fax. Este formato é simples de elaborar pela flexibilidade da informação que pode ser fornecida pelos laboratórios participantes. A desvantagem do recebimento de dados em papel é que os resultados de todos os laboratórios participantes deverão ser recolhidos pelo operador do programa de AEQ, um processo que é demorado e vulnerável a erros. Um formulário para recolha de dados electrónico poderá ser enviado eletronicamente aos laboratórios participantes. Quando o teste do exercício estiver completo, o laboratório participante introduz os resultados no formulário e poderá devolvê-lo eletronicamente ao operador do programa de AEQ. O operador do programa de AEQ poderá então copiar e compilar eletronicamente os dados, reduzindo assim o tempo necessário à sua introdução. Embora este formato possa reduzir eventualmente os erros na introdução dos dados, são necessários controlos de validação, para garantir que os dados foram copiados com rigor. Outra adaptação do recebimento de dados electrónica é um formato existente na Internet. Este método exige a concepção e manutenção de um sistema de recebimento de dados online. Os laboratórios participantes poderão introduzir os resultados do exercício de AEQ diretamente numa base de dados online. Neste formato, não é exigida nenhuma introdução de dados pelo operador do programa de AEQ, eliminando desta forma o tempo despendido e os potenciais riscos de erro nesta fase. A desvantagem deste formato de recebimento de dados é a necessidade de recursos para conceber e manter um website funcional. Além disso, os laboratórios participantes irão dispor das infraestruturas da tecnologia de informação para que usem o sistema. Qualquer que seja o formato escolhido para o recebimento de resultados do exercício de AEQ, o formulário dos resultados deverá, na generalidade, incluir a seguinte informação:  código e nome do laboratório participante;  data da recepção e condições em que o material do exercício foi recebido;  nome do método de teste ou dos reagentes usados;  número de lote do reagente e prazo de validade;  data do teste e nome da pessoa que o efetuou;  resultados e interpretações do teste;  outras observações. 34 S E Ç Ã O 4 No Anexo 4 apresentam-se exemplos de formulários de resultados do exercício. 4.8 LOGÍSTICA Com base nas infraestruturas locais, o organizador do programa de AEQ precisará de decidir acerca do meio de transporte para os painéis AEQ a remeter aos laboratórios participantes. Deverão ser consideradas as questões sanitárias e de segurança para todas as pessoas que possam se expor ao material do exercício, incluindo os mensageiros e profissionais dos correios. Estas pessoas deverão receber formação sobre o modo de manusear o material de exercício com segurança, em caso de ruptura ou vazamento na embalagem. Os exercícios do programa de AEQ deverão ser embalados e rotulados em conformidade com os regulamentos postais por meio terrestre ou aéreos locais ou internacionais, conhecida como Associação Internacional do Transporte Aéreo (IATA), se aplicável. Para efeitos da IATA, o material do exercício poderá ser enviado como amostras de diagnóstico e não como material perigoso. Os regulamentos da IATA exigem uma tripla embalagem específica devidamente rotulada. Resumindo, os frascos contendo material do exercício são selados numa embalagem estanque secundária, que contenha suficiente material para absorver o volume total do material do exercício dentro da embalagem, em caso de vazamento ou quebra. A embalagem secundária deverá ser colocada em outras embalagens capazes de proteger o seu conteúdo de danos físicos, durante o seu transporte (Figura 3). Figura 3. Esquema da embalagem tripla, de acordo com as normas da IATA para envio de amostras de diagnóstico Fonte: IATA, Montreal, Canada. A embalagem externa deverá ser rotulada para indicar que contém material patológico. O nome e endereço do programa de AEQ deverá ser descrito no exterior da embalagem, tal como o nome e endereço do laboratório participante a quem o material do exercício irá ser remetido. 35 5 Planeamento e funcionamento de um programa de AEQ para testes de ITT Há dois tipos de planos necessários para orientar a aplicação de um programa de AEQ: um é o plano anual, que descreve as principais características do programa e as atividades do seu operador, ao longo de um ano de vigência do programa. O segundo plano é uma descrição detalhada das atividades necessárias, começando pela produção de material até à finalização do relatório do programa de AEQ. É preciso um plano desta natureza para cada exercício de AEQ. 5.1 ELABORAÇÃO DE UM PLANO ANUAL DE PROGRAMA DE AEQ Antes do início de um programa de AEQ, o operador do programa deverá identificar e planear os processos para o ano de vigência do programa. Os planos deverão ser documentados e conter informação que corresponda aos objetivos e ao desenho de cada exercício do ano do programa de AEQ. Os planos anuais deverão conter referências aos procedimentos operacionais padrão, protocolos e outros documentos que contenham informações mais pormenorizadas. Normalmente, os planos anuais para programas de AEQ deverão conter as seguintes informações:  nome, endereço e contactos do operador do programa;  nome, endereço e contactos dos subcontratantes envolvidos no programa de AEQ, se for caso disso;  objetivos específicos do programa de AEQ para todo o ano, por exemplo, um objetivo anual poderia ser analisar as capacidades laboratoriais para obter resultados reproduzíveis em diferentes ocasiões ao testar os mesmos materiais;  atividades para garantir que as amostras do banco de amostras são adequadas e cumprem as necessidades do exercício anual;  número e tipo de participantes que se espera incluir no programa de AEQ;  taxa de participação ou mecanismos de financiamento;  informação sobre os materiais e analitos que os laboratórios participantes deverão identificar, medir ou testar em cada exercício do programa de AEQ; 36 S E Ç Ã O 5  requisitos de produção, controlo da qualidade, armazenamento e distribuição do material do exercício de AEQ;  calendários e datas para a produção de exercícios de AEQ, envio aos laboratórios participantes e prazos para apresentação de resultados pelos participantes;  procedimentos para testes de homogeneidade e de estabilidade;  descrição da análise estatística a usar, se necessário, e critérios de avaliação do desempenho dos laboratórios participantes;  datas previstas para a disponibilização dos resultados de referência e dos relatórios finais aos laboratórios participantes. 5.2 ELABORAÇÃO DO PLANO PARA UM EXERCÍCIO ESPECÍFICO DE AEQ Embora o plano anual do programa de AEQ seja um documento de alto nível que define largamente os atributos do programa, é também necessário um plano específico que oriente a preparação de cada exercício de AEQ. Este plano mais específico deverá documentar o modo como cada exercício será executado individualmente. O plano específico deverá contemplar as seguintes informações para cada exercício:  responsabilidades de cada membro da equipe na preparação do exercício ;  finalidade do exercício;  número de laboratórios envolvidos no exercício;  critérios de seleção e quantidades necessárias de cada um dos materiais do exercício, de forma a satisfazer a finalidade do exercício;  nome do exercício, número do painel e código;  identificadores para materiais individuais do exercício;  processos de produção e testes de verificação detalhados;  calendário e datas para a produção dos painéis do exercício, envio aos laboratórios participantes e prazo para a apresentação dos resultados e distribuição dos relatórios;  referências a protocolos para homogeneidade e estabilidade específicas de cada exercício;  referências a todos os documentos, formulários e registos envolvidos no exercício. Recomenda-se a elaboração de uma lista de verificação do processo e da calendarização, em simultâneo com o plano específico do exercício de AEQ; isto garantirá que os processos ocorrerão de forma sistemática, possibilitando a rastreabilidade de todo o processo de AEQ. 5.3 SELEÇÃO DE MATERIAL PARA OS EXERCÍCIOS DE AEQ Deverão ser selecionadas amostras apropriadas que satisfaçam as finalidades do exercício específico de AEQ a partir do banco de amostras. Cada exercício deverá conter materiais da mais alta qualidade, cada um dos quais com situação serológica definida, baseada nos resultados dos P L A N E A M E N T O E F U N C I O N A M E N T O D E U M P R O G R A M A . . . 37 testes realizados na caracterização e registados na base de dados das amostras (ver secção 4). Um exercício de AEQ consiste em um conjunto de materiais de exercício negativos e positivos. A quantidade de material do exercício negativo e positivo e a ordem pela qual ele é apresentado no painel deverá variar de exercício para exercício, de modo a evitar que os laboratórios participantes prevejam a composição do exercício. Deverão ser preparadas quantidades de frascos suficientes tanto para suprir as necessidades dos laboratórios participantes como para permitir que o operador do programa mantenha frascos de reserva. Os frascos de reserva são necessários no caso dos laboratórios participantes exigirem substituições por perda ou quebra, ou para repetição do teste devido a um erro. Os frascos de reserva poderão ainda ser necessários para o operador do programa realizar testes internos durante o período do exercício para efeitos de estabilidade, para arquivos ou uso futuro. O volume total exige que cada material do exercício seja calculado tendo em consideração o seguinte:  número total de laboratórios participantes no exercício ;  número de painéis adicionais de exercício que deverão ser preparados (a usar como painéis de substituição ou para fins de investigação);  número de frascos de cada material do exercício necessário para testes de homogeneidade e de estabilidade;  volume necessário para cada frasco;  volume perdido ou margem de erro durante a produção do painel (através da centrifugação e da distribuição). 5.4 PREPARAÇÃO DOS MATERIAIS DOS EXERCÍCIOS Uma vez identificadas as amostras apropriadas, estas serão retiradas do banco de amostras. A remoção de amostras deverá ser atualizada na base de dados do banco de amostras. As amostras terão de ser descongeladas antes de usar. Para volumes menores, o plasma poderá ser descongelado em banho-maria a 30–37°C, conforme o tempo que levar a descongelar (normalmente não mais de 30 minutos). O tempo de descongelamento pode variar consoante a temperatura do banho-maria e do volume do plasma8. Uma vez descongelado, os volumes da mesma amostra deverão ser misturados se a amostra tiver sido guardada em mais do que um frasco. Se as amostras misturadas forem utilizadas no exercício de AEQ, o processo de mistura das amostras deverá ser realizado nesta fase. As alíquotas da mesma amostra ou de diferentes amostras identificadas para serem agrupadas deverão ser homogeneizadas antes de serem processadas. 8 Extended life plasma: a framework for preparation, storage and use, 2nd edition. Australian and New Zealand Society of Blood Transfusion Ltd.; 2013. 38 S E Ç Ã O 5 O volume total de cada amostra é centrifugado até formar grânulos de matéria particulada e o sobrenadante é decantado para outro frasco estéril. Cada amostra deverá ser testada de novo antes da introdução nos frascos individuais para criar material do exercício, e comparada com os resultados originais da caracterização do banco de amostras. Assim, verificar-se-á de que não houve misturas nem degradação durante o armazenamento. Se os resultados forem diferentes dos esperados, a amostra não é adequada para usar no exercício e recomenda-se a seleção de uma amostra alternativa. 5.5 DISTRIBUIÇÃO DO MATERIAL DOS EXERCÍCIOS Os frascos de polipropileno com tampa de rosca externa com o tamanho adequado deverão ser previamente rotulados antes do envasamento, com etiquetas auto-adesivas, previamente validadas para a aderência aos frascos em várias temperaturas e condições de armazenamento. As etiquetas auto-adesivas dos frascos deverão conter a seguinte informação:  Nome do programa de AEQ  número ou código do exercício  identificador do material do exercício  volume do material contido no frasco. Recomenda-se que a informação das etiquetas sejam impressas eletronicamente, se possível, para minimizar os erros de cópia. A rotulagem de todos os tubos para um material do exercício deverá ser separada, para evitar a mistura de tubos já rotulados. O envasamento de todos os frascos com um só material do exercício deverá ser concluído antes de se passar ao próximo, para reduzir o risco de contaminação, de mistura de materiais, ou de envasamento indevido de um frasco errado. Recomenda-se aliquotar primeiro os materiais negativos e, só depois, os materiais positivos. Em termos ideais, a manipulação do material biológico deverá processar-se dentro de uma câmara de segurança biológica. Uma vez envazados os frascos com material do exercício, os painéis podem ser agrupados numa embalagem de painel já etiquetada. Os rótulos deverão conter a seguinte informação:  Nome do programa de AEQ  número ou código do exercício  número do material do exercício no painel  temperatura recomendada de armazenamento  prazo de validade  símbolos de perigo biológico. Os painéis agrupados do exercício deverão ser armazenados entre 2°C e 8°C até estarem prontos a despachar, o que deverá processar-se com a maior brevidade possível após a produção estar concluída. P L A N E A M E N T O E F U N C I O N A M E N T O D E U M P R O G R A M A . . . 39 5.6 VERIFICAÇÃO DA HOMOGENEIDADE E ESTABILIDADE Independentemente do material biológico usado, será necessário garantir que o material do exercício está adequadamente homogeneizado e que todos os laboratórios participantes recebem material equivalente, de composição uniforme com variações mínimas (material homogéneo). A verificação da homogeneidade do material deverá ser concluída para cada distribuição de exercício de AEQ. Processar-se-á da seguinte forma:  testando uma selecção aleatória de números representativos de frascos finais de cada material do exercício;  após o processamento e a distribuição do material do exercício pelos frascos, mas antes do seu envio aos laboratórios participantes. O número de frascos escolhidos para o teste de homogeneidade deverá ser suficiente para avaliar uma possível variação do material do exercício. Para cada material do exercício que foi introduzido, será selecionado aleatoriamente um número de frascos adequado. A ISO 17043 determina: “Se necessário, o operador ou os seus subcontratantes deverão usar uma seleção estatisticamente aleatória de um número representativo de amostras de um lote de material de teste, para avaliar a homogeneidade do material”. Não há uma definição do número de frascos necessários para o teste de homogeneidade, embora, como orientação, seja usual selecionar um mínimo de 10% ou 10 dos frascos produzidos, conforme o que for maior. Contudo, o número de frascos escolhidos para o teste de homogeneidade não deverá ultrapassar a capacidade de uma simples ronda de teste, para evitar variações entre as rondas. É importante assegurar que a reatividade do material não se alterou em nenhum dos frascos selecionados e testados para a homogeneidade. Deverá proceder-se a um extenso protocolo de homogeneidade e documentar todos os registos. Para o teste de homogeneidade, recomenda-se que seja usado o primeiro método de teste na estratégia validada de testagem do operador do programa, para o marcador adequado. Se um só frasco não produzir o resultado esperado, pode resultar na remoção do exercício de todos os frascos que contenham esse particular material de exercício. Inclui-se no Anexo 5, um exemplo de um protocolo para testes de homogeneidade. 5.7 VERIFICAÇÃO DA ESTABILIDADE É necessário validar a estabilidade de materiais de modo a garantir que eles se coadunem à sua finalidade quando chegam aos laboratórios participantes e que não ocorra nenhuma perda de integridade do material. A temperatura, o tempo, o tipo de material biológico, as propriedades dos agentes patogénicos e outros fatores podem contribuir para a perda de integridade do material. A estabilidade do material pode ser testada através de diferentes mecanismos:  deixar frascos fechados, à temperatura ambiente, pelo período de tempo que se espera que o material do exercício seja distribuído aos laboratórios participantes, seguido da repetição do teste para confirmar a reatividade;  realizar estudos acelerados de estabilidade a diferentes temperaturas no laboratório;  simular estudos de estabilidade em tempo real. 40 S E Ç Ã O 5 A preparação e a execução de um protocolo de estabilidade poderá monitorizar e avaliar a taxa de eventual deterioração do material do exercício. A estabilidade do material do exercício deverá ser monitorizada desde o momento da conclusão da produção do material do exercício de AEQ até, pelo menos, à data de encerramento do exercício. O número de frascos escolhidos para testes de estabilidade deverá ser suficiente para permitir que a testagem ocorra a intervalos regulares, durante todo o exercício. A monitorização regular ajudará a localizar o momento da deterioração, caso ele ocorra. Recomenda-se que a estabilidade continue a ser monitorizada durante um curto período de tempo após a conclusão da data do exercício, caso venha a ser necessária alguma resolução de problemas. Como no caso do teste de homogeneidade, é recomendável que o primeiro teste da estratégia de testagem do operador do programa para o marcador adequado à caracterização do material do exercício seja usado para testes de estabilidade. O protocolo de estabilidade precisa de ser documentado antes do início do mesmo, tendo em conta o prazo do exercício e fatores que possam influenciar a estabilidade do material. Os critérios de aceitação deverão também ser documentados no protocolo de estabilidade, sublinhando as ações tomadas, caso os resultados mostrem que a estabilidade de um material do exercício foi deteriorada. Ao elaborar os critérios de aceitação é importante prever uma variação intra-ronda e inter-rondas quando se analisam os resultados de estabilidade. Apresenta-se no Anexo 6 um exemplo de um protocolo para testes de estabilidade. O envio de material para um ou mais laboratórios participantes distantes, que depois o devolve para repetição dos testes é também usado para testes de estabilidade. Porém, isto apenas verifica a estabilidade do material enquanto está em trânsito, a menos que seja mantido nos laboratórios participantes durante todo o exercício, antes de ser devolvido. 5.8 EMBALAGEM E EXPEDIÇÃO Deverá incluir-se documentação apropriada para o exercício específico de AEQ dentro da embalagem. Esta deverá incluir as instruções de manuseamento do material do exercício e o modo de registar os resultados, se forem usados formulários dos resultados em papel. Embora os modelos para esta documentação devam ser elaborados no início do programa, é importante rever e verificar todos os documentos antes da sua distribuição, de modo a garantir que não existem contradições, ambiguidades ou omissões na informação, e que a informação se refere ao exercício específico a ser distribuído. Os documentos anexos deverão ser selados com uma capa protetora e presos ao exterior da embalagem secundária. Se o operador do programa de AEQ tiver decidido usar formulários electrónicos para os resultados, estes deverão ser enviados por via electrónica aos participantes, simultaneamente com o envio do material do exercício. É útil uma lista com os códigos de registo dos laboratórios participantes quando se embalam os exercícios, para garantir que não falta nenhum P L A N E A M E N T O E F U N C I O N A M E N T O D E U M P R O G R A M A . . . 41 laboratório. É igualmente importante ter um protocolo de embalagem, incluindo para verificar se foi embalada a combinação correta do material do exercício e respectivos documentos, para cada um dos laboratórios participantes. O Anexo 7 apresenta um exemplo de um registo de distribuição de exercícios e respectivos resultados que podem ser usados como lista de verificação da embalagem. Se os exercícios forem todos distribuídos num só dia, basta anotar a data e o local nas colunas “Documentação embalada”, “Materiais embalados” e “Exercício distribuído” por cada laboratório participante. A data da embalagem e da distribuição deverá ser registada para todos os laboratórios participantes a quem sejam enviados os exercícios em datas diferentes. 5.9 RECEBIMENTO E PRAZO PARA OS RESULTADOS AEQ Os laboratórios participantes deverão apresentar o formulário preenchido dos resultados do exercício ao operador do Programa de AEQ, até à data limite estabelecida para aceitação dos resultados. Os resultados recebidos após este prazo não serão aceites, especialmente se os processos de validação da estabilidade não se prolongarem para além da data limite. Para encorajar e relembrar os laboratórios participantes, o operador do Programa de AEQ poderá contactá-los uma semana antes de terminar o prazo para lhes lembrar que deverão apresentar os seus resultados. Após serem recebidos pelo operador do Programa de AEQ, os formulários preenchidos com os resultados deverão ser carimbados com a data e arquivados, de forma a poderem ser facilmente consultados. O operador do Programa de AEQ poderá decidir fazer uma rápida análise dos formulários de resultados recebidos, de modo a garantir que os formulários estão bem preenchidos e que toda a informação está legível, podendo ainda identificar quaisquer erros grosseiros. 5.10 COMPILAÇÃO DOS RESULTADOS DA AEQ Os resultados do exercício de AEQ oriundos dos laboratórios participantes deverão ser compilados de forma a facilitar a sua análise. A abordagem para compilar os resultados de um exercício de AEQ irá depender da forma como os dados foram recolhidos e do tipo de dados apresentados. Os resultados do exercício de AEQ deverão ser compilados num único local que seja fisicamente seguro e confidencial. Embora seja possível o recebimento baseado num manual dos resultados, é preferível um sistema electrónico que permita o fácil armazenamento e análise. É essencial que o operador do Programa de AEQ tenha instalado um processo de gestão da qualidade dos dados. Os sistemas baseados num manual exigem um grau superior de gestão, para garantir a minimização dos erros de transcrição e de entrada. O número de vezes que os dados são manuseados deverá ser reduzido para evitar erros. Tanto para métodos manuais como electrónicos do recebimento de resultados, é necessário o armazenamento seguro dos dados e a manutenção dos registos, incluindo o apoio adequado de dados electrónicos. O tipo de resultados de teste apresentados pelos laboratórios participantes (qualitativos ou quantitativos) por um ou mais métodos de testagem terão de ser considerados num sistema concebido para recebimento e análise. 42 S E Ç Ã O 5 A inclusão de cada item da informação de apoio (como o nome do método de teste, os números do lote, os prazos de validade, o operador, a data do teste, etc.) irá depender da forma como os dados serão analisados. 5.11 ANÁLISE DOS RESULTADOS DA AEQ De modo a analisar os resultados dos exercícios de AEQ, o resultado de referência para cada material do exercício terá de ser determinado pelo operador do Programa de AEQ. Este resultado de referência, normalmente, é atribuído com base nos testes de caracterização realizados durante a produção do material do exercício de AEQ. No entanto, ocasionalmente, o resultado de referência poderá ser atribuído com base num consenso de resultados de um grupo de laboratórios. Em termos ideais, isto raramente ocorre quando o material do exercício se comporta de forma inesperada e dá resultados desviados dos resultados de caracterização. Os resultados de referência deverão ser claros aos laboratórios participantes. A complexidade da análise dos resultados realizada poderá depender:  da maturidade do Programa de AEQ e dos conhecimentos técnicos do operador do Programa de AEQ;  das finalidades do exercício de AEQ;  dos recursos disponíveis do operador do Programa de AEQ. Outra importante consideração é o prazo de tempo para fornecer feedback e relatórios aos laboratórios participantes. Uma comunicação atempada do desempenho laboratorial no exercício de AEQ poderá ser mais útil do que uma análise aprofundada que exigiria um longo período de tempo a completar. Uma abordagem simples para analisar os resultados do exercício de AEQ deverá realçar o seguinte:  os laboratórios participantes que reportaram resultados diferentes dos resultados de referência;  os métodos de teste que produzem resultados que divergem dos resultados de referência. Certas abordagens avançadas para analisar os resultados do exercício de AEQ poderão incluir:  a investigação do desempenho de vários métodos de teste, através do agrupamento dos dados em subconjuntos com base em métodos de teste comuns;  a investigação do desempenho dos diferentes lotes de reagentes usados pelos laboratórios participantes;  a análise dos resultados quantitativos, usando instrumentos estatísticos. Cada um dos laboratórios participantes deverá receber uma análise individual do seu desempenho no exercício. O relatório individual do laboratório deverá especificar claramente quaisquer resultados reportados pelo laboratório participante que sejam diferentes dos resultados de referência determinados pelo operador do Programa de AEQ. É importante relembrar que apenas serão usados os códigos laboratoriais ao reportar ou avaliar o desempenho dos laboratórios participantes, de forma a manter a confidencialidade. P L A N E A M E N T O E F U N C I O N A M E N T O D E U M P R O G R A M A . . . 43 Quando se analisarem conjuntos de dados ou se usarem instrumentos estatísticos, é importante ter consciência que as comparações feitas entre pequenos números de resultados poderão não ser válidas. 5.12 ANÁLISE ESTATÍSTICA DOS RESULTADOS DE UM EXERCÍCIO DE AEQ Os resultados quantitativos podem ser analisados estatisticamente para determinar se algum dos resultados dos participantes para um material do exercício difere significativamente dos outros. Para executar este tipo de análise, os dados devem ser divididos em grupos, de forma a que o conjunto de dados analisados contenha apenas resultados gerados pelo mesmo método de teste (grupo de pares). É necessário remover estatisticamente os resultados inesperados que possam distorcer o cálculo da média e do desvio padrão de um conjunto de dados. Os métodos estatísticos para identificar resultados inesperados incluem o teste de Grubbs e o filtro de Tukey9. Podem ser determinados o resumo estatístico do conjunto de dados que descreve a média, o desvio padrão e o coeficiente da variação. Esta informação fornece os valores “alvo” e permite que o laboratório participante compare o seu desempenho com o dos outros laboratórios participantes que usam o mesmo método de teste. O operador do Programa de AEQ deverá ter em consideração que se o número dos resultados num conjunto de dados for inferior a cinco, o perfil estatístico gerado poderá não fornecer uma representação rigorosa dos resultados esperados para a amostra deste método de teste. Por isso, para pequenos conjuntos de dados, não será útil nem adequada a notificação de um perfil estatístico. São também normalmente usadas estatísticas sólidas para analisar os resultados do grupo de pares AEQ, as quais são recomendadas pelo ISO 13528:2005, Statistical methods for use in proficiency testing by interlaboratory comparisons. 5.13 PREPARAÇÃO DE RELATÓRIOS AEQ As conclusões da análise dos resultados apresentadas para o exercício deverão ser documentadas num relatório que será distribuído a todos os laboratórios participantes. Para garantir a confidencialidade dos laboratórios participantes, só poderão ser usados códigos de identificação no relatório. Deste modo, a informação acerca da qualidade global do testes entre os laboratórios participantes poderá ser comunicada sem quebra de confidencialidade. Será prioritário um curto prazo de devolução do relatório do exercício de AEQ para apresentar aos laboratórios participantes. Um exercício de AEQ capta uma panorâmica do desempenho de cada um dos laboratórios participantes num ponto específico do tempo. O feedback rápido permite que os laboratórios participantes investiguem e tomem 9 Barnett V, Lewis T. Outliers in statistical data, 3rd edition. Wiley; 1994. Tukey’s filter: http://www.statisticshowto.com/tukey-iqr-test/. 44 S E Ç Ã O 5 as necessárias ações corretivas de eventuais deficiências identificadas, enquanto o problema ainda é relevante para o laboratório. Os atrasos no feedback acerca do desempenho poderão reduzir o valor de uma análise aprofundada dos resultados conseguidos. Em situações em que não for possível um feedback rápido pelo operador do Programa de AEQ, poderá ser aceitável para os laboratórios participantes um procedimento alternativo de enviar um relatório preliminar logo após o encerramento do exercício, seguido do relatório do exercício numa data posterior. 5.14 RELATÓRIO PRELIMINAR O relatório preliminar é um resumo da composição dos materiais do exercício de AEQ. Não inclui qualquer análise dos resultados e, por isso, poderá ser preparado com antecedência. Um relatório preliminar deverá incluir:  o nome, data e código do exercício de AEQ;  a caracterização dos resultados do teste; e  os resultados de referência atribuídos a cada material do exercício. Esta informação do relatório preliminar permitirá que os laboratórios participantes analisem rapidamente o seu desempenho no exercício e, se necessário, implementem as ações corretivas. 5.15 RELATÓRIO FINAL O relatório do exercício de AEQ deverá incluir o seguinte:  o nome e a informação de contacto do operador do Programa de AEQ;  o nome e código do exercício de AEQ;  uma descrição dos materiais fornecidos no exercício de AEQ, incluindo métodos de produção e pormenores do modo como os resultados de referência foram obtidos;  os resultados do teste de caracterização para cada material do exercício;  a finalidade do exercício de AEQ;  uma descrição dos métodos de análise dos dados usados;  o número de laboratórios participantes no exercício;  uma avaliação individual dos resultados de cada laboratório participante, sublinhando os que apresentaram diferenças dos resultados de referência. Para além disso, a seguinte informação poderá promover o valor do Programa de AEQ:  um resumo dos resultados reportados para cada material do exercício por método de teste usado;  problemas sistemáticos relativos ao método específico de teste ou ao número de lote do reagente usado pelos laboratórios participantes;  aconselhamento aos laboratórios participantes sobre o modo de resolver os erros laboratoriais; P L A N E A M E N T O E F U N C I O N A M E N T O D E U M P R O G R A M A . . . 45  observações gerais e debates acerca dos resultados apresentados para o exercício. É preciso ter em atenção que o relatório do exercício de AEQ dever ser claro e informativo. Criar um modelo base de um relatório garantirá a consistência da informação prestada para cada exercício e aumentará a eficácia do processo de redação de um relatório. As observações e recomendações feitas pelo operador do Programa de AEQ acerca dos resultados apresentados para um exercício deverão ser construtivas e baseadas em evidências, não devendo incluir juízos de valor. O relatório de um exercício de AEQ pode fornecer aconselhamento e sugestões para ações preventivas quando se deduza que possa haver razões para erro. Em função do tipo, frequência e gravidade dos erros detectados nos exercícios de AEQ, o operador do Programa de AEQ poderá escolher oferecer outras ações para ajudar um laboratório participante a retificar os processos de testagem (ver secção 6). Incluem-se no Anexo 8 exemplos de um relatório preliminar e análises que podem ser incluídas no relatório final do exercício de AEQ. 5.16 CERTIFICADOS DE PARTICIPAÇÃO A participação em Programas AEQ é um importante elemento do sistema de gestão de um laboratório. Assim, os laboratórios podem ser solicitados a apresentar provas dessa participação e do seu desempenho. Embora os relatórios AEQ e a demonstração de ações corretivas na sequência da detecção de erros sejam as melhores provas, muitos laboratórios participantes poderão ainda pedir um certificado de participação. A emissão de um certificado anual de participação, especificando os número de exercícios efetuados, poderá ser uma forma positiva de encorajar a continuidade da participação. Os certificados de participação podem ser emitidos de várias formas. Por exemplo, os certificados podem ser emitidos após cada Programa de exercícios de AEQ ou uma vez por ano. O operador do Programa de AEQ terá necessidade de definir o que significa “participação”. Os certificados podem ser concedidos pela participação no AEQ, independentemente do desempenho ou com base em níveis mínimos de desempenho. Em qualquer dos casos, o operador do Programa de AEQ deverá definir previamente os níveis mínimos de participação ou de desempenho e comunicar esses requisitos aos laboratórios participantes. 46 6 Monitorização do desempenho dos laboratórios, feedback e educação A monitorização do desempenho envolve e definição de normas para um funcionamento aceitável e a identificação dos laboratórios participantes que não conseguem cumprir essas normas. O objetivo do Programa de AEQ de identificar o desempenho insatisfatório pretende oferecer aconselhamento e apoio para ajudar esses laboratórios a melhorar o seu desempenho. A necessidade de monitorizar o desempenho individual dos laboratórios – e a implementação de ações corretivas e preventivas apropriadas em caso de desempenho insatisfatório persistente – será determinada pela situação da AEQ no seio do sistema nacional de qualidade existente. 6.1 DEFINIÇÃO DE NORMAS PARA UM DESEMPENHO ACEITÁVEL O primeiro passo da monitorização do desempenho é definir normas de desempenho satisfatório, insatisfatório e, eventualmente, “no limite”. O potencial significado clínico dos erros deverá ser considerado na definição das normas de desempenho aceitável. Ao criar um Programa de AEQ é, assim, aconselhável tornar o programa operacional por um certo período de tempo, como um ano, com seguimento inicial dos erros como acima se descreve, mas sem monitorização formal do desempenho nem pontuação. Durante este tempo, a informação pode ser recolhida sobre os níveis atuais de desempenho, dentro de cada categoria de testes, nomeadamente o desempenho do teste rápido ou kit de testes para ITT. Este processo permitirá a definição de padrões realisticamente exequíveis de desempenho aceitável, assegurando, ao mesmo tempo, que os principais erros, como um resultado falso negativo para ITT, sejam definidos como insatisfatórios. Para a monitorização do desempenho, não deverá haver diferenciação entre resultados incorretos, causados por erros técnicos ou processuais (como a incorreta transcrição de resultados ou a transposição do material do exercício), embora estes possam ser analisados e notificados em separado. Um resultado incorreto numa transfusão de sangue efetuada num laboratório ou no banco de sangue de um hospital poderá ter as mesmas graves consequências, independentemente da causa desse erro. Por essa razão, é aconselhável basear a monitorização do desempenho – e a pontuação numérica, se for usada – em interpretações feitas em vez das reações serológicas registadas para cada teste. Para além dos resultados incorretos, o não M O N I T O R I Z A Ç Ã O D O D E S E M P E N H O D O S L A B O R A T Ó R I O S . . . 47 retorno dos resultados ou o seu envio tardio também constituem um desempenho insatisfatório. Os padrões de desempenho deverão ser estabelecidos independentemente pela comissão consultiva, que integra representantes dos laboratórios participantes e peritos da área. A comissão consultiva deverá ser responsável pela revisão regular das definições de desempenho insatisfatório e fazer alterações, se for necessário, de modo a refletir melhorias no desempenho global. 6.2 SISTEMAS NUMÉRICOS DE PONTUAÇÃO PARA A MONITORIZAÇÃO DO DESEMPENHO Os sistemas de pontuação podem ser desenvolvidos de forma a permitirem a monitorização do desempenho individual dos laboratórios. Embora esses sistemas de pontuação possam objetivamente mostrar que progressos estão a ser alcançados, a pontuação pode ter a desvantagem de fazer com que os laboratórios manipulem ou alterem os resultados com receio de obterem uma pontuação insatisfatória. Tal comportamento limita gravemente o valor da participação no Programa de AEQ. É, por isso, importante que o operador do Programa de AEQ enfatize junto do pessoal dos laboratórios participantes, dos seus supervisores e chefes, a importância de abordagens não punitivas ao desempenho AEQ. Um sistema de pontuação que utilize pontos de penalização é mais fácil para avaliar a significância clínica e para usar como identificação de um desempenho insatisfatório numa base cumulativa. A pontuação pode ser avaliada para refletir a potencial significância clínica dos erros cometidos. O sistema de classificação deverá ser determinado antecipadamente e comunicado aos laboratórios participantes como parte do manual de informação do Programa de AEQ. As classificações cumulativas poderão ser usadas para identificar um desempenho insatisfatório persistente, assim como laboratórios com desempenho “no limite”. Uma vez criado o sistema, os pontos cumulativos deverão ser atribuídos em cada relatório do exercício. Se tal não for possível, os pontos cumulativos poderão ser fornecidos a cada laboratório num resumo anual, para mostrar as tendências do seu desempenho individual. Apresentam-se no Anexo 9 exemplos de sistemas de classificação numérica para monitorização do desempenho. 6.3 SEGUIMENTO DO DESEMPENHO INSATISFATÓRIO Quaisquer ações de seguimento dos Programas AEQ deverão respeitar os procedimentos estabelecidos pela comissão consultiva. Se o papel de um Programa de AEQ é realizar ações de seguimento, o âmbito dessas intervenções deverá ser documentado e consistente com os recursos disponíveis ao operador do Programa de AEQ. Por exemplo, poderá ser feito um contacto inicial pelo operador do Programa de AEQ para determinar as possíveis causas de erro e oferecer aconselhamento. Se as intervenções do operador do Programa de AEQ não produzirem melhorias subsequentes no desempenho, dever-se-á enviar uma carta ao chefe do laboratório para reportar a situação, formalizar o aconselhamento 48 S E Ç Ã O 6 oferecido e sugerir soluções possíveis. Estes procedimentos deverão ser executados para garantir que, se as ações de um laboratório se tornarem insatisfatórias, os seus progressos continuarão a ser monitorizados, até se chegar a um desempenho satisfatório consistente. O pessoal do Programa deverá ter uma atitude construtiva mas sem juízos de valor relativamente ao desempenho insatisfatório. Qualquer ajuda oferecida deverá basear-se em evidências e estar em sintonia com as normas ou orientações nacionais, se as houver. Exemplos de erros graves incluem resultados falsos negativos para quaisquer marcadores ou múltiplos resultados falsos positivos, incapacidade de identificar um erro burocrático intencional ou uma troca de amostras. As opções para a assistência contínua podem incluir:  prestar aconselhamento específico, a longo prazo e recorrente sobre melhores oportunidades;  fornecer mais material do exercício de AEQ para resolver problemas;  fornecer formação prática de laboratório;  facilitar visitas de supervisão ou de auditoria ao laboratório participante, para identificar deficiências, incluindo a nível de comunicação com o chefe do laboratório. O capacidade do operador do programa para empreender estas atividades irá depender dos recursos que lhes foram afetados. A comissão consultiva deveria defender vivamente a atribuição desses recursos, pois o benefício da participação no AEQ apenas poderá ser maximizado se essas atividades de apoio forem disponibilizadas. Deverá ser realizada anualmente uma análise longitudinal do desempenho dos laboratórios participantes. Isto garantirá que qualquer laboratório participante com problemas consistentes de um exercício de AEQ para outro irá ser adequadamente seguido. Para ajudar a monitorizar o desempenho dos laboratórios participantes, o operador do programa de AEQ poderá optar por guardar um registo do desempenho dos laboratórios participantes num ficheiro ou folha de cálculo, para facilitar a sua análise. 6.4 AUTO-AVALIAÇÃO Na ausência de qualquer tipo de monitorização ou seguimento do desempenho pelo Programa de AEQ, a comparação entre os resultados individuais dos laboratórios e os obtidos por outros laboratórios será um meio útil de sublinhar a necessidade de melhorias. Este processo poderá melhorar os padrões sem a intervenção de uma fonte externa. 6.5 EDUCAÇÃO A principal finalidade de um Programa de AEQ é melhorar o desempenho e prestar assistência que possa enfrentar quaisquer problemas detectados. Assim, a educação deverá estar inerente a todas as atividades de um Programa de AEQ. Ela poderá ser fornecida aos laboratórios numa base individual ou a todos os laboratórios participantes e outros profissionais pertinentes. M O N I T O R I Z A Ç Ã O D O D E S E M P E N H O D O S L A B O R A T Ó R I O S . . . 49 O programa tem um papel educacional particularmente importante no que respeita se refere a erros cometidos no exercício de AEQ individualmente pelos laboratórios participantes. Quando há disponibilidade de recursos, o pessoal do Programa de AEQ poderá ajudar os laboratórios a identificar as causas profundas dos erros e dar sugestões para alterações na prática e nos procedimentos para evitar a sua recorrência. Os erros no exercício de AEQ podem dever-se a questões técnicas específicas; porém, aparentemente os erros simples, como erros de transcrição que resultam no registo de um resultado incorreto de ITT, poderão ser indicativos de problemas e deficiências mais latos no sistema de qualidade de um laboratório. A educação poderá ser ministrada de modo mais vasto sob a forma de relatórios sobre o desempenho global de diferentes técnicas e tecnologias, que fornecem pontos de aprendizagem específicos sobre as melhores práticas. Uma vez bem instalado o programa, poderá também ser possível, com a ajuda da comissão consultiva, organizar uma reunião científica anual ou um seminário para que os laboratórios participantes resolvam os problemas decorrentes dos exercícios de AEQ. O operador do programa deverá, sempre que possível, comunicar a informação gerada pelo programa, não apenas aos participantes, mas também a um público mais vasto, fazendo apresentações em reuniões locais, nacionais e internacionais e através de publicações. Os dados do Programa de AEQ poderão ainda ser usados como base para redigir e rever orientações, tornando a educação acessível a todos os que trabalham nesta área da transfusão de sangue. 50 7 Monitorização e avaliação de um programa de AEQ Para que um programa de AEQ progrida, é importante monitorizar a sua evolução e avaliar regularmente o seu impacto. Esta avaliação fornecerá igualmente provas objetivas de apoio à continuidade do programa e será crucial para a sua sustentabilidade. A avaliação deverá ser realizada pelo menos uma vez por ano, sendo redigido um relatório da mesma. 7.1 INDICADORES Apresentam-se abaixo os indicadores do processo e dos resultados que podem ser usados para avaliar o êxito deste programa. Deverá reconhecer- se, no entanto, que uma melhoria relativa aos indicadores dos resultados poderá ser influenciada por fatores não diretamente relacionados com a participação num programa de AEQ, como a introdução de melhores reagentes ou tecnologias. Indicadores do processo e dos resultados Os exemplos de indicadores do processo e dos resultados que poderão ser recolhidos anualmente incluem:  frequência e presenças nas reuniões da comissão consultiva;  percentagem de laboratórios participantes;  percentagem de laboratórios que comunicam os resultados de cada exercício – tardiamente ou nunca;  número de laboratórios que registam os resultados dos testes adicionais para avaliação;  número de problemas registados relativamente ao funcionamento do programa;  número de reclamações recebidas e resolvidas relativas ao funcionamento do programa;  número de vezes em que o material do exercício não conseguiu satisfazer os requisitos documentados;  feedback positivo da parte dos participantes;  resolução de problemas e atividades educativas executadas;  publicações ou apresentações do programa. M O N I T O R I Z A Ç Ã O E A V A L I A Ç Ã O D E U M P R O G R A M A D E A E Q 51 Indicadores dos resultados Os exemplos dos indicadores de resultados incluem:  percentagem de desempenho satisfatório e não satisfatório;  alterações nas pontuações globais, se aplicável;  tendências do desempenho com o mesmo material após vários exercícios;  melhorias ou alterações na testagem usada pelos laboratórios participantes;  laboratórios participantes que receberam acreditação. 7.2 IMPACTO Ao analisar os resultados, poderão determinar-se os impactos que o programa exerce ao longo de um período de tempo. Por exemplo, a percentagem de desempenho satisfatório versus não satisfatório ou as alterações na pontuação global podem inferir a redução de resultados incorretos das amostras dos dadores e, desse modo, a minimização do risco de transmissão; a melhoria nas práticas da testagem poderá traduzir-se numa economia dos custos e no tempo dos técnicos. Quando as partes interessadas e os financiadores do programa conhecerem estes impactos, a continuidade do financiamento será mais fácil de justificar. 7.3 RELATÓRIO ANUAL Deverá ser elaborado um relatório anual do programa a distribuir pelas partes interessadas, incluindo ministério da saúde, comissão consultiva e outros, como os laboratórios participantes. O seu conteúdo poderá incluir:  resumo dos exercícios distribuídos;  resumo do desempenho global, realçando algumas tendências;  resumo dos indicadores de processo;  itens de aprendizagem dos exercícios;  pormenores da evolução e dos desafios no seio do programa;  avaliação global do impacto do programa;  recursos humanos e financeiros, se for caso disso. 52 Glossário Este glossário foi preparado a partir de definições incluídas no ISO 9000:2006, Quality management systems: fundamentals and vocabulary, ou no ISO 15189:2013, Medical laboratories: requirements for quality and competence. Sempre que existiam definições sobre estas normas, foi fornecida a referência do documento. As definições em itálico destinam- se a definir o uso dos termos ou expressões relevantes neste documento, e a forma como esses termos se relacionam entre si. Acreditação Procedimento através do qual uma autoridade faz o reconhecimento formal de que a organização é competente para realizar tarefas específicas (ISO 15189:2013). Auditoria Processo sistemático, independente e documentado para obter evidências e avaliá-las objetivamente, de forma a determinar até que ponto são satisfeitos os critérios de auditoria (ISO 9000:2006). Competência Capacidade demonstrada para aplicar os conhecimentos e aptidões (ISO 9000:2006). Avaliação das competências Processo para avaliar uma aptidão individual para aplicar conhecimentos e competências. Documentação Políticas, instruções e registos escritos envolvidos no fornecimento de um produto ou serviço. Eficácia Alcance das atividades realizadas e dos resultados obtidos (ISO 9000:2006). Material do exercício O material que foi preparado a partir das amostras e que constitui um painel de AEQ. Avaliação externa da qualidade (AEQ) Avaliação externa do desempenho de um laboratório, usando material de exercício de conteúdo conhecido mas não divulgado, e comparação com o desempenho de outros laboratórios. G L O S S Á R I O 53 Programa de avaliação externa da qualidade Programa formal organizado por uma instituição reconhecida. Poderá tratar-se de um programa local ou organizado a nível nacional, regional ou internacional. Hemovigilância Monitorização, notificação e investigação de eventos adversos relacionados com todas as atividades de transfusão de sangue. Controlo interno da qualidade Procedimentos que verificam a consecução da qualidade pretendida dos resultados (ISO 15189:2013). Estes podem incluir procedimentos para monitorizar a capacidade diária de reprodução dos resultados dos testes e detectar os principais erros no processo analítico. Sistema de gestão Sistema para criar uma política de qualidade e objetivos de qualidade e para atingir esses objetivos (ISO 9000:2006). Marcador Características específicas dos materiais de exercício incluídos no programa de AEQ, e.g. anticorpos anti-VIH, antigénio VIH, anticorpos anti-Treponema. Painel Um conjunto de materiais de exercício de AEQ. Procedimento Modo específico de realizar uma atividade ou um processo (ISO 9000:2006). Processo Conjunto de atividades interrelacionadas ou interativas que transformam entradas em produtos (ISO 9000:2006). Qualidade Medida em que um conjunto de características inerentes preenchem os requisitos (ISO 9000:2006). Gestão da qualidade Atividades coordenadas para orientarem e controlarem uma organização no que refere à qualidade (ISO 9000:2006). Amostra Espécime, de preferência de grande volume, que foi processada, testada e armazenada num banco de amostras para ser eventualmente usada como material de exercício. 54 G L O S S Á R I O Espécime Porção discreta de um fluido corporal, sopro, cabelo ou tecido retirado para exame, estudo ou análise de uma ou mais quantidades ou propriedades assumidas para aplicar à totalidade (ISO 15189:2013). Procedimento operacional padrão Modo específico de realizar uma atividade ou um processo que esteja documentado, implementado e mantido (ISO 15189:2013). Teste Determinação de uma ou mais características, de acordo com um procedimento (ISO 9000:2006). Validação Confirmação através do fornecimento de provas objetivas de que os requisitos para uma finalidade ou aplicação específica foram cumpridos (ISO 9000:2006). Anexos Os seguintes anexos são apresentados para informação e como exemplos sobre os quais os operadores de programas prospectivos de AEQ possam querer basear a sua documentação e outros aspectos da concepção do seu programa, com as adequadas modificações locais. 1. Questionário preliminar para potenciais laboratórios participantes 2. Formulário de registo da AEQ 3. Ficha de instruções para os exercícios 4. Formulário de resultados dos exercícios 5. Protocolo para testes de homogeneidade dos materiais de exercício 6. Protocolo para os testes de estabilidade da testagem de exercício 7. Registo das distribuições de exercícios e resultados recebidos 8. Análise e relatório sobre os exercícios 9. Sistemas numéricos de pontuação. 56 Anexo 1 Questionário preliminar para os laboratórios participantes Programa de avaliação externa da qualidade para rastreio de ITT nas dádivas de sangue Preencher este questionário relativamente ao rastreio de infecções transmissíveis por transfusão e medidas gerais de qualidade no seu laboratório. Parte 1. Pormenores de contacto Nome da instituição: Nome do contacto: Departamento: Endereço: Telefone: Fax: Endereço electrónico: Parte 2. Informação sobre o laboratório 1. Pessoal: 2. Número de amostras processadas anualmente dos: Dadores de sangue Outros (favor especificar) A N E X O 1 57 3. Queira indicar qual o rastreio de ITT executado no seu laboratório e o método de teste usado: Rastreio obrigatório* VIH HCV HBV Sífilis Doença de Chagas HTLV I/II Paludismo ITT rastreadas no seu laboratório        ITT para as quais seu laboratório gostaria de ter um programa AEQ        * Rastreio exigido pelo país. Marcadores Nome dos kits de teste usados no seu laboratório Nome do fabricante dos kits de teste Instrumento Volume necessário (ml) Incluindo repetição dos testes e volume morto Métodos de testes usados 4. As amostras independentes (não o controlo do kit e testes ) para controlo interno da qualidade (IQC) são incluídas em cada uma das testagens?  Sim  Não Em caso afirmativo, o desempenho destes IQC são registados e monitorizados regularmente?  Sim  Não 5. O laboratório possui uma microcentrifugadora?  Sim  Não Em caso afirmativo, quais as RPM mínimas e máximas a que ela funciona? 6. O seu laboratório tem um frigorífico?  Sim  Não 58 A N E X O 1 Parte 3. Preferências do esquema de AEQ Quantos materiais por painel?  1-3  5  10 Quantos exercícios por ano?  1  2  3 Observações gerais: 59 Anexo 2 Formulário de registo da AEQ Nome da instituição: Nome do contacto: Departamento: Endereço postal: Endereço de entrega: Telefone: Fax: Endereço electrónico: Outro contacto para recepção de relatórios, se necessário Endereço electrónico: Queira indicar os exercícios do Programa de AEQ em que o seu laboratório gostaria de participar. Cada exercício inclui cinco materiais de exercício. A participação em dois exercícios anuais é considerada o mínimo aceitável. Exercício número VIH HCV HBV Sífilis Doença de Chagas HTLV I/II Paludismo 1        2        3        60 Anexo 3 Ficha de instruções para os exercícios Finalidade do uso Este é um painel codificado de materiais para exercício, cada um com reatividade conhecida para: [inserir marcadores incluídos no painel para avaliação]. Destina-se a ser usado para avaliar o desempenho dos laboratórios que realizam rastreios de rotina das dádivas de sangue para ITT. Material fornecido  X (inserir número) frascos de soro para os exercícios de Y [inserir volume] rotulados: 1A, 1B, …  Fichas de resultados Instruções de armazenamento, manuseamento e testagem do material de exercício  Misturar em vórtex e depois centrifugar todo o material de exercício antes do teste  Processar o material de exercício junto com as amostras de rotina dos dadores e da mesma forma como elas seriam normalmente processadas pelo seu laboratório.  Advertência: O material de exercício é potencialmente infeccioso e deverá ser manuseado com as precauções universais de segurança.  O material deverá ser armazenado a 2–8°C durante o tempo do exercício. Instruções para testagem do material de exercício  Testar o material de exercício da mesma forma como as amostras de rotina dos dadores seriam normalmente testadas, usando a estratégia utilizada no seu laboratório. Instruções para preenchimento do formulário de resultados  Assinale a caixa relevante, quando tiver várias opções de resposta.  Registar apenas os resultados de um kit de teste em cada página. Fotocopiar a página relevante para mais resultados.  Definições das abreviaturas usadas no formulário: (exemplo) — R: Recativo — N: Negativo — INC: Inconclusivo Instruções para devolução dos resultados  Garantir a devolução dos resultados antes da data de encerramento. 61 Anexo 4 Formulário para os resultados dos exercícios Código de identificação do exercício: 01/04 (exemplo) Código de registo do laboratório: Nome do contacto: Nome da instituição: Número de telefone: Endereço electrónico: Data em que o seu laboratório recebeu o painel: Os materiais foram recebidos em boas condições?  Sim  Não Observações: (Se os painéis forem recebidos em condições não satisfatórias, poderão obter-se painéis de substituição, contactando o operador do programa de AEQ para mais informação sobre os detalhes abaixo). A data de encerramento do exercício é 01/04 - DD/MM/AAAA Queira devolver os formulários preenchidos com os resultados para [inserir contactos do operador de AEQ]: Operador do programa de AEQ: Nome de contacto da AEQ: Endereço: Telefone: Fax: Endereço electrónico: 62 A N E X O 4 FORMULÁRIO DOS RESULTADOS DO EXERCÍCIO: EIA Exercício 01/04 Código de registo do laboratório: Nome do kit do teste: 1a ronda: Operador: Data do teste: Número de lote do kit: Prazo de validade do kit: 2a ronda: Operador: Data do teste: Número de lote do kit: Prazo de validade do kit: Supervisor: Resultados ID do material de exercício Rácio S/Co (1ª ronda) Rácio S/Co (2ª ronda) Interpretação do kit de testeDO (A) Cut-off (B) S/Co (A÷B) DO (A) Cut-off (B) S/Co (A÷B) Rep 1 Rep 2 Rep 1 Rep 2 1A  R  N  INC 1B  R  N  INC ...  R  N  INC ...  R  N  INC 1X  R  N  INC Observações: Nome do operador que comunica os resultados: A N E X O 4 63 FORMULÁRIO DOS RESULTADOS DO EXERCÍCIO: TESTE RÁPIDO Nome do programa / ID: ID do participante: Número de lote do kit de teste: Prazo de validade do kit: Iniciais do operador: ID do material de exercício Data do teste Primeiro leitor Segundo leitor Interpretaçãoc do resultado final ID do leitora Ab bar / spotb Ag bar / spotb Control bar / spotb ID do leitorc Ab bar / spotb Ag bar / spotb Control bar / spotb a Iniciais. b Neg., Pos., Não Aplicável (N/A). c Negativo, Reativo, Inválido. 64 Anexo 5 Protocolo para o teste de homogeneidade do material dos exercícios  Exemplo: A composição do painel do exercício ID: 01/04 contém 5 materiais de exercício rotulados: 1A, 1B, 1C, 1D e 1E.  Os 80 frascos de cada material de exercício foram produzidos e separados em alíquotas durante a produção.  10 frascos representativos de cada material de exercício de AEQ (referir a secção) são selecionados para o teste de homogeneidade.  Usando um gerador de número aleatório, registar 10 números de frascos selecionados para o teste de homogeneidade (e.g. frascos 15, 25, 31, 47, 58, 66, 70, 80, 12, 22).  Os mesmos números dos frascos terão que ser reservados para cada material de exercício.  Os frascos selecionados deverão ser renumerados com novos códigos de homogeneidade para garantir a rastreabilidade durante o teste (e.g. 1A:H1, 1A:H2 ……… 1A:H10, etc.)  Armazenar os frascos para o teste de homogeneidade a 2–8°C, até à conclusão do teste.  Testar cada frasco uma vez no kit de teste adequado na mesma ronda de teste.  Qualquer material de exercício que tenha um resultado diferente do resultado de referência, deverá voltar a ser testado duas vezes. A interpretação final do teste para este material de exercício basear- se-á no consenso dos três resultados do teste. Registar os resultados no formulário apropriado (ver a Quadro seguinte).  Antes de descartar, armazenar os frascos de homogeneidade a 2–8°C, até que os resultados de homogeneidade sejam revistos e aceites pelo operador do programa de AEQ.  Critérios de aceitação: Um material de exercício será aceite para inclusão num painel, se todas as interpretações dos resultados do teste para cada frasco estiverem de acordo com o resultado de referência. A N E X O 5 65 EXEMPLO: RESULTADOS DO TESTE DE HOMOGENEIDADE PARA O PAINEL DO EXERCÍCIO ID: 01/04 Material do exercício: 1A 1B 1C 1D 1E Referência: resultado Reativo Negativo Negativo Reativo Reativo H1 Reativo Negativo Negativo Reativo Reativo H2 Reativo Negativo Negativo Reativo Reativo H3 Reativo Negativo Negativo Reativo Reativo H4 Reativo Negativo Negativo Reativo Reativo H5 Reativo Negativo Negativo Negativo* Reativo H6 Reativo Negativo Negativo Reativo Reativo H7 Reativo Negativo Negativo Reativo Reativo H8 Reativo Negativo Negativo Reativo Reativo Aceitação: Aprovado Aprovado Aprovado Reprovado* Aprovado * Repetir o teste duas vezes. A interpretação final do teste para este material de exercício basear-se-á no consenso dos três resultados do teste. 66 Anexo 6 Protocolo para o teste de estabilidade do material dos exercícios  Exemplo: A composição do painel do exercício 01/04 contém 5 materiais de exercício rotulado 1A, 1B, 1C, 1D e 1E.  80 frascos de cada material de exercício foram produzidos e separados em alíquotas durante a produção, que incluiu 6 frascos de cada material de exercício a ser selecionado para o teste de estabilidade.  Os frascos selecionados deverão ser renumerados com novos códigos de estabilidade para garantir a rastreabilidade durante o teste (e.g. 1A:S1, 1A:S2, 1A:S3, 1A:S4, 1A:S5 e 1A:S6).  Identificar o tempo e as condições de temperatura a que o material de exercício ficará exposto durante todo o exercício. EXEMPLO: ATIVIDADE E CALENDÁRIO DO PAINEL DE EXERCÍCIO: MATERIAL DE EXERCÍCIO 1A 01/04 Atividade Calendário Material de exercício Condições de temperatura de armazenagem Pós-produção Dia 0 2–8°C Início da expedição Dia 4 S1 37°C Final da expedição Dia 11 S2 37°C Data do início do exercício Dia 12 S3 2–8°C Data intermédia do exercício Dia 25 S4 2–8°C Data de encerramento do exercício Dia 32 S5 2–8°C Armazenamento de 7 dias após data de encerramento Dia 39 S6 2–8°C  Armazenar os frascos de estabilidade a 2–8°C durante 4 dias até os painéis do exercício serem enviados aos laboratórios participantes. Remover o frasco de estabilidade 1A:S1 no dia 4, testar o kit de teste adequado para o analito.  Passar os restantes 5 frascos de estabilidade para 37°C ± 1°C e armazenar durante 7 dias.  Remover o frasco de estabilidade 1A:S2 no dia 11, testar o kit de teste adequado para o marcador. A N E X O 6 67  Retirar os restantes 4 frascos de estabilidade e armazenar a 2–8°C. Testar os seguintes frascos do kit de teste adequado para o analito da seguinte maneira: — 1A:S3 no dia 18 — 1A:S4 no dia 25 — 1A:S5 no dia 32 — 1A:S6 no dia 39.  Se algum material de exercício tiver um resultado diferente do resultado de referência, deverá repetir- se o teste. A interpretação final do teste para este material de exercício basear-se-á no consenso dos três resultados do teste. Registar os resultados no respectivo formulário (ver abaixo).  Critérios de aceitação: Os critérios para uma adequada estabilidade devem basear-se no efeito que a instabilidade terá sobre a incerteza do resultado do participante e, por conseguinte, sobre a avaliação da aceitabilidade dos resultados de um participante. EXEMPLO: RESULTADOS DO TESTE DE ESTABILIDADE PARA O PAINEL DE EXERCÍCIO ID: 01/04 Material do exercício: 1A 1B 1C 1D 1E Referência: resultado Reativo Negativo Negativo Reativo Reativo S1 Reativo Negativo Negativo Reativo Reativo S2 Reativo Negativo Negativo Reativo Reativo S3 Reativo Negativo Negativo Reativo Reativo S4 Reativo Negativo Negativo Reativo Negativo* S5 Reativo Negativo Negativo Reativo Negativo* S6 Reativo Negativo Negativo Reativo Negativo* Aceitação: Estável Estável Estável Estável Instável * Repetir o teste duas vezes. A interpretação final do teste para este material de exercício basear-se-á no consenso dos três resultados do teste. 68 Anexo 7 Registo das distribuições dos exercícios e resultados recebidos NÚMERO DE ID DO PAINEL: Código do laboratório Pacote de documentação Pacote de materiais Distribuição do exercício Resultados recebidos Observações 0001 0002 0003 0004 0005 0006 0007 0008 0009 0010 0011 0012 0013 0014 0015 0016 0017 0018 0019 0020 0021 0022 0023 0024 69 Anexo 8 Análise e relatórios dos exercícios RELATÓRIO PRELIMINAR ID do material* Tipo de amostra Observações Situação anti- VIH-1 Resultado de referência p24 1 Plasma Negativo Negativo 2 Plasma agrupado Positivo Negativo 3 Plasma agrupado Positivo Negativo 4 Plasma agrupado Negativo Negativo 5 Plasma agrupado Positivo Negativo 6 Plasma Negativo Negativo 7 Cultura de VIH-1 sobrenadante diluída em plasma humano negativo A amostra contém ~5000 pg/ mL de sobrenadante da cultura de células do subtipo B Negativo Positivo 8 Plasma Negativo Negativo 9 Plasma agrupado Positivo Negativo 10 Plasma Negativo Negativo * Identificação. 70 A N E X O 8 ID d o m at er ia l M ur ex VI H -1 .2 .O A g/ A b EI A (S /C o* ) Si st em as ge né tic os B io -R ad V IH -1 A g* * EI A (S /C o) Si st em as ge né tic os B io - R ad V IH -1 A g co nfi rm at ór io VI H -1 w es te rn b lo t Si tu aç ão A nt i V IH -1 R es ul ta do s de r ef er ên ci a p2 4 p1 8 p2 4 p3 1 p3 4 gp 4 1 p5 3 p6 8 In te rp re ta çã o do r es ul ta do do t es te 1 0 .4 1 0 .2 0 N ão t es ta do N ão t es ta do N ão a pl ic áv el N eg at iv o N eg at iv o 2 1 4 .9 6 0 .2 4 N ão t es ta do – + + – + + + + + + + + Po si tiv o Po si tiv o N eg at iv o 3 1 5 .2 1 0 .2 1 N ão t es ta do – + + + – + + + + + + + + + + + Po si tiv o Po si tiv o N eg at iv o 4 0 .4 8 0 .2 5 N ão t es ta do N ão t es ta do N ão a pl ic áv el N eg at iv o N eg at iv o 5 1 8 .8 2 0 .2 4 N ão t es ta do + + + + + + + + + + + + + + + + + + + Po si tiv o Po si tiv o N eg at iv o 6 0 .3 9 0 .2 5 N ão t es ta do N ão t es ta do N ão a pl ic áv el N eg at iv o N eg at iv o 7 0 .3 1 4 0 .6 6 3 7 .8 3 N ão t es ta do N ão a pl ic áv el N eg at iv o Po si tiv o 8 0 .3 7 0 .2 6 N ão t es ta do N ão t es ta do N ão a pl ic áv el N eg at iv o N eg at iv o 9 1 8 .5 7 0 .2 5 N ão t es ta do + + + + + + + + + + + + + + + + + + Po si tiv o Po si tiv o N eg at iv o 1 0 0 .4 1 0 .2 0 N ão t es ta do N ão t es ta do N ão a pl ic áv el N eg at iv o N eg at iv o * A m os tr a: r ác io r es id ua l, em q ue ≥ 1 é r ea tiv o. * * A nt ig én io . CARACTERIZAÇÃO DAS AMOSTRAS QUE INCLUÍAM A ID DO PAINEL DE AEQ ANTI-VIH A N E X O 8 71 EXEMPLO DE ANÁLISES A INCLUIR NO RELATÓRIO FINAL DO EXERCÍCIO Percentagem de resultados falsos negativos e falsos positivos, por marcador Falso positivo % Falso negativo % Sífilis 0 0 0 0 TND = 100 TPD = 28 VIH 10 9.80 0 0 TND = 102 TPD = 68 Anti-HTLV-I/II 0 0 0 0 TND = 56 TPD = 19 HCV 0 0 0 0 TND = 85 TPD = 26 HBsAg 0 0 2 7.1 TND = 90 TPD = 28 1§Total 10 2.2 2 1.1 TND = 448 TPD = 175 TND = Total de determinações realizadas em amostras negativas. TPD = Total de determinações realizadas em amostras positivas. Desempenho dos participantes por marcador ID do participante VIH HBsAg Sífilis HCV anti-HTLV-I/II 1 A A A A A 2 A A A A – 3 A A A A A 4 A A A A A 5 A A A A A 6 A A A A A 7 A A A A A 8 A A A A A 9 A A A A – 10 A A A A – 11 B2 A A A A 12 B2 A A A A 13 B2 A A A – 14 A C A A – A = 100% de concordância. B1 = Foi reportado um resultado falso positivo (≤ 5% do total de determinações dos participantes individuais). B2 = Foi reportado um resultado falso positivo (> 5% do total de determinações dos participantes individuais). C = Resultado falso negativo. – = Não realizado. 72 A N E X O 8 Resultados falsos positivos e falsos negativos (%) notificados para cada material de exercício 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7,69 7,14 4,35% ID do material % FP % FN ANÁLISE POR KIT DE TESTE O exemplo da tabela abaixo mostra o número de resultados falsos notificados para cada kit de teste de sífilis usado pelos participantes. Tabelas semelhantes poderão ser elaboradas para outros marcadores. Kits de testes FPR % TND FNR % TPD Architect syphilis TP 0 0 30 0 0 9 Sífilis Murex ICE 0 0 15 0 0 3 Cartão Macrovue RPR 0 0 10 0 0 2 Trepanostika TP recombinante 0 0 10 0 0 5 Total 0 0 65 0 0 19 TND = Total de determinações realizadas em amostras negativas TPD = Total de determinações realizadas em amostras positivas. FPR = Resultado falso positivo. FNR = Resultado falso negativo. 73 Anexo 9 Sistemas numéricos de pontuação O MÉTODO MAIS SIMPLES DE PONTUAÇÃO APENAS AVALIA O ESTADO FINAL DE CADA MATERIAL COM PONTUAÇÃO TOTAL DE 100% ID painel AEQ Ano Pontuação Resultados esperados Positivo Negativo Negativo Positivo Positivo ID do material 1 2 3 4 5 Resultados dos participantes Negativo Positivo Negativo Negativo Positivo 80% MÉTODO DE PONTUAÇÃO PARA RESULTADO DO TESTE E INTERPRETAÇÃO FINAL ID painel AEQ Ano Resultados dos participantes ID do material (resultados esperados) Kit de teste 1 kit de teste 2 Kit de teste 3 Situação final Pontuação 1 (Negativo) Não reativo Não realizado Não realizado Negativo 2 de 2* ou 20 2 (Positivo) Reativo Reativo Não reativo Positivo 3 de 4 ou 15 3 (Positivo) Reativo Reativo Reativo Positivo 4 de 4 ou 20 4 (Negativo) Reativo Não reativo Não reativo Inconclusivo 2 de 4 ou 10 5 (Positivo) Reativo Reativo Reativo Positivo 4 de 4 ou 20 Pontuação total 85% Pontuação máxima = 100 com atribuição de 20 pontos a cada material de exercício. Para cada material de exercício há até quatro respostas necessárias. * Pontuação máxima atribuída: ambas as respostas possíveis corretas (os kits de teste 2 e 3 não precisavam de respostas para o material 1). 74 A N E X O 9 MÉTODO DE PONTUAÇÃO PARA OS RESULTADOS DOS TESTES, INTERPRETAÇÃO FINAL E ALGORITMO SEGUINTE Número do painel AEQ Ano Resultados dos participantes Pontuação ID do material (resultados esperados) Kit de teste 1 Kit de teste 2 Kit de teste 3 Situação final Resultados do teste (80%) Algoritmo do teste (20%) 1 (Negativo) Não reativo Não reativo Não reativo Negativo 16/16 0/4* 2 (Positivo) Reativo Reativo Não reativo Positivo 12/16 4/4 3 (Positivo) Reativo Reativo Reativo Positivo 16/16 4/4 4 (Negativo) Reativo Não reativo Não reativo Inconclusivo 8/16 4/4 5 (Positivo) Reativo Reativo Reativo Positivo 16/16 4/4 Pontuação total 84% Pontuação máxima = 100 pontos, com atribuição de 20 pontos a cada material de exercício. Para cada material de exercício há até quatro respostas necessárias, valendo 4 pontos cada e 4 pontos atribuídos se o algoritmo for seguido. * Não foi atribuído nenhum ponto a mais pelo seguimento do algoritmo, porque o participante continuou a testar nos kits de teste 2 e 3, apesar de obter um resultado negativo no kit de teste 1 para o material 1. Avaliação confidencial do desempenho por marcador: Esquema de avaliação externa da qualidade – ID do painel: ID do participante: Sífilis VIH HTLV HCV HBsAg A A A A A Critérios de qualificação: A 100% de resultados corretos, sem resultados falsos positivos nem falsos negativos. B1 Foi reportado um resultado falso positivo (≤ 5% do total de determinações realizadas pelo participante). B2 Foi reportado um resultado falso positivo (> 5% do total de determinações realizadas pelo participante). C Foi reportado um resultado falso negativo. 978-92-4-851043-4

建立输血传播感染血液筛查室间质量评价项目 ——实施指南 Establishing External Quality Assessment Programme for Screening of Donated Blood for Transfusion-Transmissible Infections: Implementation Guide 翻 译: 王拥军、郑小凡、周华平、董 杰、丁 威、胡秋月、 朱立苇、韩文娟、俞 丽、黄纪红、吴丹霄 （浙江省血液中心） 审 校: 刘 鸿 王 迅 责任单位： 上海市血液中心 世界卫生组织输血合作中心 联系方式： wangxun@sbc.org.cn 版 权 说 明 世界卫生组织于 2016 年发行英文原版书名： Establishing External Quality Assessment Programme for Screening of Donated Blood for Transfusion‐Transmissible Infections: Implementation Guide ©世界卫生组织 2016年 世界卫生组织已将本书英文原版的中文翻译和发表权利授予上海市血液中 心，上海市血液中心对中文版本的质量和中英文一致性负全部责任，当中英文版 本间出现任何不一致时， 以英文原版为准。 建立输血传播感染血液筛查室间质量评价项目——实施指南 ©上海市血液中心2022年 目 录 致谢 导言 1. 室间质量评价 1.1 EQA 作为质量体系的一部分在TTI 筛查中的应用 1.2 评估 1.3 室间质量评价 1.4 EQA的目标和益处 1.5 EQA项目 2. 建立TTI筛查地EQA项目 2.1 组织机构 2.2 顾问委员会 2.3 技术和行政支持 2.4 信息管理系统 2.5 财务 2.6 EQA项目的质量体系 2.7 参评实验室 2.8 试运行 2.9 建立EQA项目的操作步骤 3. 参评实验室 3.1 EQA项目资料手册 3.2 参与规则 3.3 注册 4. 建立EQA项目时实际考虑因素 4.1 范围 4.2 EQA活动模式 4.3 EQA项目目标 4.4 质评样本的来源 4.5 建立样本库 4.6 制备候选质评样本 4.7 质评活动的文件 4.8 物流 5. TTI检测EQA项目的计划和实施 5.1 制定年度EQA计划 5.2 制定具体的EQA活动计划 5.3 EQA样本的选择 5.4 EQA样本的准备 5.5 EQA样本的分装 5.6 验证均一性和稳定性 5.7 稳定性验证 5.8 包装和分发 5.9 EQA结果的收集和截止日期 5.10 EQA结果的整理 5.11 分析EQA结果 5.12 EQA结果的统计分析 5.13 EQA报告的编制 5.14 初步报告 5.15 最终报告 5.16 参与证书 6. 实验室性能监控、结果反馈和教育 6.1 设定可接受的性能标准 6.2 性能监控的数值评分系统 6.3 不合格操作的跟踪 6.4 自我评估 6.5 教育 7. EQA项目的监测和评估 7.1 指标 7.2 影响 7.3 年度报告 术语 附录 附录 1 参评实验室初步调查问卷 附录 2 室间质量评价登记表 附录 3 质评活动说明 附录 4 质评活动结果表 附录 5 质评样本均一性试验方案 附录 6 质评样本的稳定性试验方案 附录 7 质评样本分发和结果提交的记录 附录 8 质评活动的分析和报告 附录 9 数值评分系统

致 谢 世界卫生组织服务和安全部输血安全项目组谨在此感谢下列输血传播感染筛查室间 质量评价专家为制定本指南作出的贡献。 作者 Ms Susan Best 及其同事 澳大利亚墨尔本血清学参比实验室 作者同时感谢以下参与WHO发布的《输血实验室实践操作的室间质量评价——建 立血型血清学室间质量评价指南》（WHO/EHT/04.09）的专家，该指南为本出版物的配 套材料。 Ms Jenny White, 项目执行经理，英国Watford输血实验室实践NEQAS Mr Robin Knight, 红细胞免疫血液学服务部经理，英国北伦敦血液中心，国家血液中心 编辑团队和参与者 Dr Wilai Chalermchan, 资深实验室顾问，泰国 MOPH —美国CDC 合作项目 (TUC) Dr Marcia Mitiko Otani, 血清学质量控制部主管，巴西圣保罗血液中心 Dr Neelam Dhingra, 协调员，患者安全和质量改进，WHO安全与服务部 Dr Noryati Abu Amin, 医学官员，血液和输血安全，机构服务和临床干预部， WHO安全与服务部 Mr Junping Yu, 技术官员，血液和输血安全，机构服务和临床干预部，WHO安全 与服务部 审稿专家 Dr Alan Kitchen, 国家输血微生物参比实验室主任，英国NHS血液和移植 Dr Jane Carter, Amref 健康非洲，,肯尼亚内罗毕Wilson Airport, Langata Road Dr Vengetassen (Ravi) Reddy, 执行办公室主任，南非国家血液中心 Dr Vivienne James, 澳大利亚北悉尼中心海岸卫生健康机构 Dr Xun Wang, 输血传播疾病实验室主任，中国上海市血液中心 Dr Panadda Silva, 医学科学部主任/专家，泰国国家卫生部 本指南的出版由 Noryati Abu Amin博士和余俊平先生协调。世界卫生组织官员、患 者安全和质量改进协调员Neelam Dhingra 博士以及服务和临床干预小组协调员 Hernan Montenegro博士为指南的出版提供了全面指导。 本指南得到合作协议编号为GH001180 的美国疾病控制和预防中心（CDC）的支 持。内容完全由作者负责，不代表美国CDC 的官方观点。 1导 言 室间质量评价（external quality assessment，EQA）是输血服务质量体系的重要组成 部分。EQA 是对实验室整体性能的外部评估，该实验室对结果已知但保密的质评样本 进行检测，并与检测相同样本的其他实验室的性能进行比较。输血传播感染 （transfusion-transmitted infections，TTI）筛查实验室参与EQA 有助于监测和提高实验室 的性能标准。参加EQA 获得的信息，有助于实验室发现错误和实施防止其再次发生的 措施，为持续改进质量提供了机会。因此，EQA 在促进血液安全方面起着至关重要的 作用。 世界卫生组织（WHO）提倡建立国家EQA 项目，并鼓励TTI 筛查实验室参与这些 项目。国家卫生主管部门应认识到EQA 的重要性，并支持在国家的TTI 筛查网络中实 施这些项目，鼓励专业机构支持和建立EQA 项目。 《建立输血传播感染血液筛查室间质量评价项目——实施指南》旨在支持WHO 成 员国建立和实施EQA 项目，以筛查捐献血液的TTI。该指南旨在为国家卫生当局和 EQA 组织机构建立可以在国家、州、省和地区各级实施的EQA 项目提供指导。它还将 使参与的实验室深入了解有关TTI 筛查地EQA 项目的组织架构，并了解参与的益处。 本指南是WHO 出版物《输血实验室实践操作的室间质量评价——建立血型血清 学室间质量评价指南》（WHO/EHT/04.09）的姊妹篇。本指南的许多内容反映了先前出 版物中所包含的信息。这是因为EQA 的一般原则是相同的，与具体学科无关。 这里所描述的指导范围包括对所有血液进行强制性的HIV、乙型肝炎病毒和丙型肝 炎病毒以及梅毒血清学筛查。 本指南还可用于指导在特定国家或区域需要强制实施的其他病原体筛查的EQA 项目 1。虽然某些成员国家或地区采用核酸检测对人类免疫缺陷病毒（艾滋病病毒）、乙 型肝炎病毒和丙型肝炎病毒进行了筛查，但建立一个用于核酸检测的EQA 项目不在 本指南的范围内，因为这需要采取不同的方法来获取样本、定性和分析，以及额外的基 础设施和严格的后勤条件。 本指南旨在为处于不同发展阶段的组织机构建立EQA 项目提供支持。如果最初不 可能实现这里所述的所有要素，则应考虑采用分阶段办法。即使设立一个基本的小型项 目，也能对提高标准产生重大影响。在TTI 筛查中建立EQA 项目时，应首先包括对临 1 Screening donated blood for transfusion-transmissible infections: recommendations. Geneva: World Health Organization; 2010. 2床上最重要的检测项目的评价；然后，随着项目的进一步发展，扩展参与评价的检测项 目的范围。 本指南介绍了建立和实施TTI 筛查EQA 项目的原则。应根据这些原则组织EQA 项目，但也应适当考虑到国家内部可能存在的TTI 筛查实验室的监管和质量体系机制。 31.室间质量评价 安全、相容的血液和血液制品的输注涉及许多过程。在献血者选择、捐献血液的采 集、制备和检测、潜在受血者样本的检测，以及受血者相容血液的发放和输注等每一个 过程中都存在差错的风险。实验室在整个输血链中起着关键的作用，在捐献血液TTI 筛 查的质量体系中的差错可能会对血液和血液制品的受者产生严重的影响。 血液安全监测项目（如英国的SHOT）表明，实验室差错是导致输血受者发病和死 亡的主要原因。 实验室的差错可能是由一些缺陷所导致，包括: ■ 献血者样本识别程序的不足； ■ 试剂储存或使用不当； ■ 设备维护不当； ■ 不完善的检测过程； ■ 记录或抄录不准确； ■ 采购实践不足； ■ 员工培训不充分。 实验室中的差错往往是多种因素综合导致的，原有的错误往往伴有审核过程不充分 的问题。 对捐献的血液进行TTI 筛查的目的是为临床输血提供安全的血液和血液制品。为确 保实现这一目标，在TTI 筛查实验室执行的质量体系应尽可能减少差错的发生。 准确的TTI 筛查对于提供安全的血液和血液制品是很有必要的。为了向临床提供安 全的血液制品，检测结果的正确抄录、审核和判读与检测操作过程本身一样同等重要。 1.1 EQA 作为质量体系的一部分在TTI筛查中的应用 在实施TTI 筛查的实验室中，室间质量评价成为监测实验室整体质量体系的一个组 成部分。国家主管部门应决定实验室应遵守何种实验室质量体系标准。这些标准可以是 在国际标准的基础上修改以适应本国的情况，也可以直接采用适用的相关国际标准。 质量体系的关键要素是以下几个。 ■ 组织管理，包括： — 质量方针和计划； — 清晰的组织结构； 4文件：与提供的产品或服务相关的 书面制度、操作指南和记录。 标准操作规程：执行一项活动或过 程的具体方法，该方法已被文件 化、可实施和被维护。 室内质量控制：验证达到预期质 量结 果 的 程 序（ISO15189 ： 2013），可能包括监控日常检测结果 的重复性和发现分析过程中的主要 差错。 审核：为获得证据并进行客观 评价，以确定满足审核准则的程度 所进行的系统的、独立的并形成文 件的过程（ISO 9000 ：2006）。 有效性：衡量策划的活动被实现的 程度及策划的结果被获得的程度 （ISO 9000：2006）。 确认：认定和提供客观证据证明特 定的预期用途或应用要求已得到 满足（ISO 9000 ：2006）。 能力评估：评估个人应用知识和技 能的能力过程。 — 指定人员负责建立和管理质量体系； — 明确所有员工的工作职责。 ■ 准确和完整的文件，包括标准操作规程和有效的 文件控制体系； ■ 对所有员工进行培训、指导和专业成长教育； ■ 设备验证、维护和校准； ■ 试剂、耗材、技术的验证， 适用时还包括软件的 验证； ■ 评估，包括： — 室内质量控制； — 内部及外部审核； — 室间质量评价。 1.2 评估 质量的持续改进要求利用内部和外部机制不断监测和 审核质量体系所有要素的有效性，以确保始终达到规定的 质量标准。 实验室质量体系的内部评估包括： ■ 在引进和使用所有活动、过程、程序、设备、试剂 和软件之前进行全面的确认； ■ 定期监测所有的关键活动，这些关键活动的结果 是可以且适合进行持续监测的； ■ 采用特定的控制措施，如质量控制样本，以监测 关键活动的操作； ■ 员工能力评估； ■ 根据有关标准或其他规定及许可的要求，制定内 部审核制度； ■ 制定差错的报告、调查和分析制度，并提供有效 的纠正和预防措施。 实验室质量体系的外部评估包括： ■ 参与适宜的EQA项目； ■ 由认可的独立机构进行外部审核。 1.3 室间质量评价 参与EQA 项目是识别实验室过程中的缺陷或改进机会 5的若干有效机制之一，并可定期提供与其他相关实验室性能水平比较的客观评价。其他 EQA 方式包括通过监督检查或审核或样本交换方式进行监督。后者为样本在实验室之 间进行交换，样本以编码的方式进行检测。对结果进行分析，以确定所有参与样本交换 的实验室是否都为同样的结果。 参加 EQA 包括检测多套由EQA 项目提供者发放给参评实验室的已知结果但未公 布的质评样本。每个参评的实验室都会收到完全相同的质评样本，这些样本的处理方式 应与常规献血者的样本相同，确保实验室在EQA 中的检测水平能准确地反映其日常检 测能力。EQA 样本检测完毕后，参评实验室将获得的检测结果提交给EQA 项目的提供 方。提供方对结果进行整理和分析，各实验室会收到本实验室的结果反馈，以及连同所 有其他参评实验室的匿名结果和参考结果，使之能够与其他参评实验室的情况进行比 较。 通过EQA 进行能力评估，实验室能够确定其体系运行的有效性，或是确定是否存 在需要纠正的缺陷。最终可根据需要，采取纠正和预防措施。因此，从该项目获得的信 息有助于提高实验室的整体工作质量，并提高输注的血液和血液制品的安全性。 即使没有建立完整的质量体系，仍可以引入EQA 作为持续质量改进过程的一部分。 1.4 EQA的目标和益处 EQA 的总目标是评价、保持以及必要时改进实验室的性能标准。鼓励建立全国性 的EQA 项目，这可通过以下途径得以实现：提高实验室对质量改进的意识，展示良好 实践的益处，以及为质量改进提供信息、教育和支持。 对参评实验室的益处 EQA 对参评实验室的益处包括以下几个方面： ■ 发现与实验室过程相关的质量改进机会； ■ 提供本实验室与其他参评实验室性能水平的比较； ■ 比较不同检测系统之间的检测性能； ■ 提供信息和教育以提高能力； ■ 鼓励良好实践； ■ 提供增加实验室可信度并增强公众信心的机会； ■ 提供实验室交流信息的网络渠道。 对卫生行政和监管部门的益处 EQA 对卫生行政和监管部门的益处包括以下几个方面： ■ 建立一个具有已知性能标准的输血实验室网络； ■ 实验室人员的培训和教育； 6认可：权威机构对一个组织有能力 执行特定工作给出正式承认的过程 （ISO 15189：2013）。 ■ 提供有用的信息有助于： — 制定标准； — 审核检测的策略； — 对试剂盒、试剂、仪器上市后的监测； — 有效利用资源； — 提高公众对输血服务的信心； — 构筑认可的支持系统。 当实验室认识到对质量的需求时，EQA 是提高标准最 有效的手段。同时最高管理层必须承诺支持能力提升所需 的变更。在没有质量体系的情况下，参与EQA 可以成为推 动质量改进的有效手段。可从EQA 的结果发现实验室操作 不佳的情况，并有助于识别对标准、指南、教育和培训的 需求，以及支持这些需求的资源。 1.5 EQA项目 EQA 应该作为正式和固定的项目进行筹划，确保有效 的计划和组织。确保统一提供质评样本和采用一个标准化的 方法对结果进行分析和报告，并对参评实验室的性能进行监 控。如果组织 EQA 的机构经认可或符合《 ISO/IEC 17043 ：2010 合格评定的原则：能力验证的一般要求》， 将有助于达到标准化的要求。 无论规模、工作量或检测的复杂程度如何，应确保所有 进行TTI 筛查的实验室实施EQA。根据现行的政策和法规体 系，实验室可自愿或强制参加EQA。在自愿参加时， 应积 极鼓励实验室为所有的常规检测项目注册EQA。 图1 展示了一种国际性、区域性和国家不同层面开发 的EQA 计划的网络模式。在每个层面，EQA 项目为参评 实验室提供EQA 样本、建议和技术支持，并通过参加其他 的EQA 项目对其自身的性能进行监控。另一个模式是鼓励 TTI 筛查实验室尽可能多地参与EQA 项目，尽可能全面地 考察其检测系统。 但是，在这种模式下，EQA 组织机构对其自身检测能 力进行评估这一原则仍非常重要。 根据各国的要求，WHO提倡在区域，国家或省级建立 EQA项目，以便于所有进行献血者TTI筛查的实验室 （无 7地 区 国 家 城市/ 州/ 省/ 区 输血服务机构 医院血库 其他实验室 国 际 图1. EQA 项目的网络 论其为何种机构类型）都可参与。 建立EQA 项目时，从WHO 或其他组织良好的EQA 项目中寻求信息和支持会有所 帮助。在国家层面，建议调查其他病理领域现有EQA 项目，寻求共享组织架构、设施 和资源的可能性。 2.建立TTI筛查地EQA项目 EQA 项目可以由国家卫生管理部门、采供血机构、专业团体或有志于此的个人发 起建立。应确定一个组织机构以及机构内的一组人员来管理和运营该项目。应组成一个 顾问委员会来监督项目的建立，并提供有关计划和组织的指南。 一个有效的EQA 项目需要多方的承诺和支持，包括国家卫生管理部门或多个部门、 专业团体、组织机构和相关人员、EQA 活动样本供应商和参评实验室等。方案的成功实 施取决于所有相关方的信任与合作，特别是参评实验室的积极参与对项目的组织至关重 要。 应明确规定所有相关人员的角色和职责，以确保项目的有效实施。 2.1 组织机构 组织机构应在相关领域具有适宜的设施和专业知识，并且信誉良好。最好由卫生管 理部门指定，并可使用专为EQA 项目的运作而分配的资金，以确保该项目的独立性和 可持续性。组织和管理EQA 项目需要花费大量时间，因此，要使项目成功运作，就必 须保证对项目有充足的认知和有充足的资源。为避免任何利益冲突，不应将涉及商业利 益的实验室设备或试剂供应商指定为组织机构。 建立EQA 项目使组织机构有机会成为信息交流实验室网络的一部分，也可使机构 国 际 8获得认可。 组织机构应参加相关领域公认的国际性或地区性的EQA 项目，证明其性能符合要 求，并且已经建立了有效的质量体系。组织机构应努力争取获得ISO/IEC 17043 ：2010 《合格评定的原则：能力验证的一般要求》的国际认可。 实施EQA 项目所需的设施和资源包括： ■ 场所； ■ 不同的检测试剂盒和方法； ■ 可开展补充或确证试验； ■ 设备； ■ 员工； ■ 技术支持； ■ 行政支持； ■ 可靠来源的质评样本； ■ 信息管理系统； ■ 充足的资金。 最为理想的是所有必要的设施和资源由组织机构提供。但是在无法做到的情况下， 应尽量避免为了从同一个机构内获得所有资源而影响EQA 项目的质量。如果EQA 项目 中的一些设施，如后勤支持等需要从不同机构中获取，则需要有效的协调系统。 在组织机构内应有一个由适当资质的员工组成的团队，在指定的负责人（EQA 项 目组负责人）带领下共同致力于提供EQA 项目。（本指南之后将该团队称为EQA 项目 的提供者。）EQA 项目的提供者应具有丰富的TTI 筛查的良好实践经验和知识，并了 解不同类型实验室常用的方法。充分的知识和了解对于确保有效规划质评活动、洞悉错 误的可能原因，以及在需要时提供有效建议的能力至关重要。 职责 EQA 项目小组负责人负责该项目的整体管理、运作和持续发展，包括以下活动。 （1） 常规管理： ■ 确定所需员工的数量及培训需求； ■ 选择人员并分配人员时间； ■ 项目的资金管理； ■ 召开顾问委员会会议； ■ 与供应商、参评实验室、顾问委员会、监管机构、媒体以及认可机构（如适用） 进行沟通； ■ 必要时选择实验室进行确证试验或验证质评活动的样本； ■ 确保为项目提供适当的信息管理系统（人工或计算机系统），以核实参评者的信 9息和结果； ■ 实施、保持和审核项目的质量体系； ■ 准备年度报告； ■ 必要时准备年度财务报表； ■ 处理投诉并采取纠正措施； ■ 出席参评实验室的会议和论坛并展示数据； ■ 项目推广。 （2） 项目实施： ■ 设计质评活动和准备质评样本； ■ 发放质评样本； ■ 跟踪结果反馈并发送提醒消息； ■ 核对数据录入、分析结果、打分并准备每个实验室的报告和总体报告； ■ 向所有参评实验室报告发现的问题，并给出改进性能的建议； ■ 向参评实验室提供解决疑难问题的建议； ■ 向卫生主管部门报告隐去实验室信息的实验室能力水平的结果以及所有涉及 政策的问题； ■ 监控实验室操作和检测试剂性能的趋势； ■ 保持参评实验室信息的更新。 （3） 项目的持续发展： ■ 紧跟输血实验室TTI筛查的发展前沿； ■ 根据需要启动和实施变更，确保项目的持续相关性； ■ 探索改进数据管理和信息提供的方法； ■ 开发项目的教育和培训功能。 2.2 顾问委员会 顾问委员会在项目的设计、规划和实施方面具有非常重要的作用。顾问委员会的成 员应包括以下成员。 ■ EQA项目小组的负责人； ■ 经过筛选的相关学科的专家； ■ 以下部门的代表： — 国家血液中心； — 参评实验室； — 专业机构； — 确证实验室（如采用）； — 卫生和监管部门。 10 EQA 项目一旦建立，顾问委员会应不间断地为项目的有效持续提供指导。 为确保有效的决策和沟通，应限制委员会的规模，选择积极参与的成员。顾问委员 会会议的次数和时间将取决于项目的规模和质评样本发放的频率，但每年至少要召开两 次会议。 委员会应根据质评活动的目的预先制定年度计划以利于质评样本的采购。顾问委员 会成员应对项目的信息保密，包括检测相关的任何细节，尤其是在本实验室也参加项目 的情况之下。 职能和职责 顾问委员会的职能和职责包括： （1） 制定以下策略： ■ 项目的战略和方向； ■ 参评规则； ■ 纳入评估的分析物和标志物； ■ 确保安全运输质评样本的监管到位； ■ 评分以及定义性能欠佳或不合格的原则； ■ 性能不合格时应采取的措施； ■ 投诉核查； ■ 发生样本盘丢失或损坏时采取的补救措施； ■ 项目推广； ■ 项目对教育和培训的作用； ■ 提供来源于独立专家的建议，帮助性能不佳的实验室。 （2） 就项目运作事宜提供专业和科学的指导，包括： ■ 计划每次质评活动的目的； ■ 建立检测策略以确定质评样本的特征； ■ 建立检测方法以确定参考结果； ■ 商定报告的内容； ■ 审核每次调查中实验室的性能水平； ■ 处理具体的问题； ■ 对参评实验室的意见作出回应； ■ 促进项目的教育和培训作用。 2.3 技术和行政支持 需要有足够的技术和行政支持来确保遵循EQA 项目的时间表。可以通过组织机构 内重新任命现有的员工，也可以雇佣适合的有资质的员工或与外部机构签约来实现。 11 技术和行政的任务包括： ■ 获取和鉴定质评样本； ■ 制备质评样本； ■ 检测质评样本，确保其适用并记录结果； ■ 质评样本的分装和贴签； ■ 包装并分发结果提交表、质评样本和最终报告； ■ 安排快递和邮政服务； ■ 输入、分析结果和其他信息； ■ 给参评实验室开具报名费的发票（如果适用）。 2.4 信息管理系统 对信息处理的要求取决于项目的规模和范围。可以不使用任何信息技术实施EQA 项目，但是使用计算机系统可以简化诸如结果生成等基本工作，并且可对结果进行更为 复杂的分析。 它的必要性在于可以： ■ 创建参评实验室详细信息的数据库（手工或电子），包括联系人姓名、地址、保 密的注册编号和需要评估的检测； ■ 准备质评活动文件，包括信件、说明、填报结果表格和地址标签； ■ 使用保密的注册编号记录参评实验室的结果； ■ 完成基本分析，包括将每个参评实验室的结果与预期结果进行比较，并对总的 结果进行校对； ■ 分析所定义的每个组内的结果，如使用特殊技术的实验室； ■ 撰写预期结果报告、每个参评实验室的结果报告以及其他的总体分析或评价。 它应该可以： ■ 以不同的方式报告数据，如直方图和散点图； ■ 生成用于性能监控和累积评分的分数； ■ 数据库可按照特定的条件进行搜索。 可以使用或开发专用的计算机软件，但是使用标准的商业软件包也可以实现其中许 多功能。 2.5 财务 必须确定建立和实施一个EQA 项目所需的资源，估算所需的费用并寻求资金支持。 表1 和表2 列出了所需资金和常见费用的大类，并列举了建立和实施一个EQA 项目所需 的设施和资源。建立的资金可来源于政府、卫生部门、专业机构、非政府组织和提供研 究资金的机构。 12 项目的持续和成功运作需要有定期稳定的资金来源。EQA 项目可以通过向参评实 验室收取费用来获取全部或部分运作的费用。尽管支付费用可使参评实验室重视该计 划，但费用金额应确保不影响实验室的参与。卫生部门应配备足够的资源以确保项目的 可持续性，使参评实验室可以负担其出资比例。 如果项目涉及商业公司，则应谨慎确保项目的独立性。 表 1. 初始资本开支 类 别 示 例 场地 ■ 为以下目的购买或租赁场所或对现有建筑物进行改造 — 办公室 — 实验室 — 冷库 — 包装和分发设施 — 记录存储 人员 ■ 招聘 ■ 需要时进行初步培训 主要设备 ■ 实验室 — 水净化系统 — 离心机 — 恒温箱 — 冰箱 — 低温冰箱 — TTI 试剂盒的专用设备，如微孔板的洗板机和读板仪 ■ 制备和分装 — 电磁搅拌器 — 冻干机（可选） — 层流柜 — 固定支架 — 泵 — 架子 ■ 储存、包装和发放 — 冷藏室或冰箱 — 热封口机 ■ 办公用品 — 复印机 — 电话 13 — 传真 ■ 信 息技术 — 计 算机 试运行 ■ 用于下列工作的原材料和员工的工作时间 — 研究设计 — 制备 — 分装和派送 — 分析和报告 14 （续表） 类 别 示 例 IT 支持（可 选用） ■ 设计以下用途的软件 — 报名注册 — 开发票 — 结果分析 — 生成报告 表 2. 持续性的常规支出 类 别 示 例 场地 ■ 租金 ■ 维护费用 ■ 日常开支 人员 ■ 工资和福利 ■ 培训和教育 ■ 差旅及相关费用 ■ 会议开支 设备 ■ 维保合同 ■ 更换和维修 质评样本 ■ 原材料 — 购置 — 制备，含过滤 实验室检测 ■ 试剂 ■ 耗材，如试管和移液管 办公 ■ 电话 ■ 文具 ■ 打印和复印耗材 信息技术 ■ 软件开发 ■ IT支持 ■ 互联网连接 分装、包装和派送 ■ 分装瓶 ■ 包装材料 ■ 邮寄、快递 会议 ■ 顾问委员会 ■ 项目参与者年会 15 ■ 研讨会 咨询费用 ■ 统计 ■ IT开发 ■ 输血专家 16 2.6 EQA项目的质量体系 EQA 项目自身必须有一个良好的质量体系。可以利用组织机构本身的质量体系的 要素。但是，有必要为EQA 项目实施一个特定、有效的质量体系，并制定一套质量方 针，说明其如何提供EQA 的服务来满足参评实验室的需求。这一方针应列入项目的质 量手册，并提及质量体系中的所有过程和程序，包含 EQA 项目特有的以及与组织机构 共有的过程和程序。 在组织 EQA 项目时会涉及许多不同的过程。因此，必须确保项目运作的每个步骤 都生成适宜的文件和记录，以便进行追溯。包括质量计划、标准操作规程、制备方案、 工作表、清单、表单、质评样本的确认结果、试剂盒的判读，以及参评实验室报告的详 细情况和结果。所有的文件和记录必须保密、安全保存并方便获取。 EQA 项目提供者可考虑采用下列途径来证明过程的质量： ■ WHO/CLSI/CDC《实验室质量管理体系手册》； ■ ISO 15189 ：2012《医学实验室：质量和能力要求》； ■ ISO/IEC 17043 ：2010《合格评定的原则：能力验证的一般要求》； ■ ISO 9001 ：2008《质量管理体系：要求》； ■ ISO 17025 ：2005《检测及校验实验室的认可准则》； ■ 在适宜的国际EQA项目中始终保持满意的性能水平。 2.7 参评实验室 在组织EQA 项目时，顾问委员会应明确需要鼓励或要求其参评的实验室属性。应 积极推广项目，鼓励充分参与，但最有效的推广途径取决于项目是自愿的还是强制性 的。 了解有参评意愿的实验室数量和类型很重要，因其影响EQA 项目的组织规 划。应向有意向的参评实验室发送初始调查表，以确定: ■ 员工配备水平； ■ 总体的工作负荷； ■ 常规的检测试验范围； ■ 使用的技术和试剂； ■ 实施的质量体系。 这些信息可用于确保对EQA 项目活动形式进行合理的设计（见 4. 建立EQA 项目 时实际考虑因素），也可用于对实验室的操作进行分类监控（见 6. 实验室性能监控、结 果 反馈和教育）。附录1 是一份初步调查表的示例，可收集有关参评实验室的一般信息。 2.8 试运行 应进行试运行以评估项目的组织、拟定的操作方法和质评活动的设计。试运行的目 17 确定组织机构 ↓ 从已建立的EQA 计划中寻求建议和支持 ↓ 设立顾问委员会 ↓ 确定资助来源 ↓ 确定样本材料的来源和贮存地 ↓ 确定有意向的参评实验室 ↓ 发送初步调查问卷到所有意向参评实验室 ↓ 邀请函 ↓ 根据提供的信息设计活动形式 ↓ 确定分发机制 ↓ 建立系统用于活动样本的制备和分发、结果处理以及性能监控 ↓ 开展试运行 ↓ 评估试运行并进行改进（如有必要） ↓ 推广项目及参评实验室注册登记 ↓ 实施项目 ↓ 监控和评估项目 的是在扩大项目的运作规模和提供正式参评之前，发现所有难以预料的后勤保障问题并 找出解决方案。 至少给有限数量的参评实验室分发两份试运行的质评样本。选择实验室应代表不同 的参评组群，涉及与组织机构不同的距离、不同的实验室规模或采用不同检测技术的实 验室。 要求参评的实验室反馈任何遇到的问题，并提出改进建议。试运行工作完成后，应 对项目运作中遇到的问题和参评实验室的意见进行评估。必要时，可以对项目的设计和 运行费用的预算作出调整。 2.9 建立EQA项目的操作步骤 建立的EQA 项目的操作步骤的概要见图2，并将在之后的章节中详细讨论。 图2. 建立EQA 项目的步骤 18 3.参评实验室 为了有效参与EQA 项目，参评实验室应认识到质量的重要性和EQA 在输血传播 感染筛查实验室质量体系中的作用。参评实验室了解EQA 的益处和项目的运行方式有 助于其遵守参与规则。这将提升项目对参评实验室自身的价值，以及提高收集到的信息 总体质量。 参评实验室的所有工作人员都应能查阅该项目分发的质量评估报告。发现的任何问 题都应在定期会议上公开讨论，并作为与实验室流程和做法有关的问题处理，而不是作 为对工作人员个人的批评。对EQA 错误的根本原因进行分析，为参评实验室实施变更 以防止类似错误的发生提供机会。 一旦项目建立并开放参与，就需要正式的注册程序，以便从参评实验室收集联系方 式和其他基本信息，并向它们提供有效参与所需的信息。这些信息应以EQA 项目信息 手册的形式提供。EQA 项目提供者还可考虑为意向参与者组织研讨会，解释该项目。 3.1 EQA项目资料手册 编制一本资料手册，说明项目的管理和运作，并为参与者提供实际指导。资料手册 应与注册表一起分发。 资料手册应包括： ■ 组织EQA项目的目的； ■ EQA项目提供者的说明和联系方式； ■ 顾问委员会的详细情况； ■ 说明参评实验室所需的承诺和参加本项目带来的益处； ■ 参与规则； ■ 描述所提供的评估方法； ■ 解释性能监控和评分系统； ■ “性能不合格”的定义和在评定为性能不合格时应采取的措施。 3.2 参与规则 参与项目的明确规则应由顾问委员会决定。这些规则应规定： ■ 对参评实验室的要求； ■ 项目提供的服务； ■ 如何利用收集的信息，包括评价数据。 参评实验室应在注册时同意上述规则。框1 和框2 列举了参与规则的例子。 19 为了最大限度地提高参评实验室的收获，并确保项目数据的有效性： ■ 应用常规使用的方法检测 EQA样本； ■ EQA 样本不应该只由最资深或最有经验的工作人员进行检测； ■ EQA 样本应与常规样品一起进行检测，不应单独存放分开检测； ■ EQA样本不应进行多次检测并比较结果，除非所有样本都以这种方式进行常规检测； ■ 一旦EQA 结果提交后，剩余的EQA样本可用于其他目的，如员工培训或能力评估； ■ 结果必须在指定的截止日期前反馈； ■ 必须接受已商定的能力评估程序并对不合格情况进行跟进； ■ 必须遵守项目数据的版权规定，以确保这些数据不得脱离既定背景发表或展示；在使用数据之 前，必须征得项目提供者或顾问委员会的许可。 为了确保项目有效运行： ■ 项目提供者、顾问委员会和参评实验室之间必须保证评估数据的机密性，除非立法规定或事先 商定有义务向第三方披露这些数据； ■ 所提供的质评样本应有可靠的质量； ■ 必须有一个明确的时间表分发样本和反馈报告； ■ 质评样本必须是安全的； ■ EQA 项目报告必须包括改进实验室能力的建议； ■ EQA 组织者必须能够就参评实验室的问题或关注点作出说明； ■ 质评样本不得送往另一个实验室进行检测，也不得与另一个参评实验室就检测结果进行沟通。 框1. 实验室参与EQA 项目的规则举例 框2. 项目规则实例 3.3 注册 在注册时，应向所有感兴趣的实验室发送一份注册表和资料手册。注册表格应要求 提供下列资料。 ■ 交接质评样本和报告的联系方式： — 参评实验室名称； — 联系人名字； — 详细的邮寄地址； — 电话号码； — 传真号码； — 在用的电子邮箱地址。 ■ 如有需要，可提供实验室或机构负责人等其他人员的姓名和地址，以便就完成 情况进行联系。 ■ 应列入参评实验室使用并希望对其进行评估的相关检测项目，使EQA 项目能够 确定质评活动的检测结果预期来自的实验室。理想情况下，参评实验室应该对 它们日常进行的所有实验进行评估。 20 注册表格还应包括由参评实验室签署的部分，表明该实验室同意遵守参与规则。注 册表格的示例在附录2。 应为每个参评实验室分配一个保密的注册编号，用于项目联络，以确保实验结果和 性能数据的保密性。编号及每个实验室的登记表格上的资料应输入项目信息管理系统。 如使用电脑资料库，这些资料的每个组成部分（例如，注册编号及地址的每一行）应以 独立栏目输入，以方便查阅资料。 参评实验室须每年重新注册，以更新其最新资料；新的注册表格须连同现有注册详 情的副本一并派发，以待确认。这将使该项目能够获得最新的技术信息和联系方式。 4.建立EQA项目时实际考虑因素 应当将从有意向参与的实验室提交的初步调查问卷中获得的信息应用于每次质评活 动的设计。只要有可能，每次质评活动都应具有教育功能，探索那些已知检测中存在较 大变异或可能对实验室构成挑战的领域。 在设计项目时，应考虑以下实际因素： ■ 范围； ■ EQA项目和质评活动的形式； ■ 项目目标； ■ 质评样本的来源和制备； ■ 质评活动的文件； ■ 结果的分析和交流。 4.1 范围 TTI 质评活动应满足参评实验室的需求，并评估用于筛查捐献血液的常规检 测方法。这可以从实验室对初步调查问卷的答复中确定。在TTI 实验室中，筛查诸如 HIV— 1/2抗体、丙型肝炎抗体、乙型肝炎表面抗原和梅毒螺旋体抗体之类的标记可能 被认为是标准的，因此应包括在EQA 项目中。根据参评实验室的检测范围和对TTI 筛查的国家法规要求，所包括的标志物可能会扩展到包括HIV—1p24抗原、乙型肝炎 核心抗体或其他标志物，如Cruzi锥虫、疟疾和HTLV—Ⅰ /Ⅱ抗体。 4.2 EQA活动模式 一年中提供的EQA 活动次数应足以对实验室程序和操作进行充分评估，并收集足 够的数据以进行累积的性能监测。每年应向参评实验室至少分发两次质评活动样本，以 在最低限度维持对实验室检测能力的信心。 21 每次EQA活动中所包含的质评样本的数量应能够检测出 实验室过程中的潜在错误。由少量样本（如 1 ～4）组成 的质评活动可能能够检出随机错误，但检测系统错误的能力 有限。由大量质评样本（如 5 ～10）组成的样本盘将具有更 大的检出随机和系统错误的能力。 4.3 EQA项目目标 每次EQA 活动都应解决特定的问题或目标，应该建立 EQA 样本盘来解决这些目标。良好的EQA 项目将为参评 实验室提供良好实验室实践的教育，并且能够发现可能发 生的不同实验室错误。 表3 列出了一些可能的目标和机制。 表 3. EQA 项目的目标和机制 目 标 机 制 参评实验室能够正确识别 样本状态吗？ 参评实验室的结果是否与 参考结果相符？ 参评实验室是否遵循制造 商的试剂盒规程？ 在结果表上收集检测项目 的详细信息，如试剂盒质控结 果的变化，判读时间 参评实验室的结果是否一 致？ 包含相同质评样本的复制品 参评实验室随着时间的推 移会产生一致的结果吗？ 在不同的质评活动中包含 相同质评样本的复制品 参评实验室是否有拒绝不 适当样本的程序？ 包含溶血的或其他不合适 的质评样本，并评估参评实验 室是否继续检测该样本 参评实验室能够识别管理 错误吗？ 包含故意贴错标签的质评样 本 比较不同检测系统的性能 根据不同的系统和技术分 析结果 验证TTI 强制筛查的覆盖范 围 包含所有强制性筛查的标志 物， 检查实验室报告 4.4 质评样本的来源 质评样本最好从采供血机构获得，因为献血者血液是质 评样本的理想选择。它可以提供大体积样本，并根据当地 质评活动的样本：标本中制备并组 成EQA 样本盘的样本。 样本盘：一套EQA 质评样本。 样本：作为潜在质评活动的样本的 标本，最好是大容量，并经处理、 检测后贮存于样本库。 标本：为检验、研究或分析一 种或多种量或特性而取出的，认为 可代表全部的独立部分的体液、呼 出气 、 毛 发 或 组 织 等 （ ISO 15189 ： 2013）。 22 法规进行了TTI 检测。但是，应该明确围绕其使用的伦理问题。理想情况下，应从捐献 者处获得知情同意，以便将其血液用于EQA 目的。 找到需要数量的TTI 阳性的捐献血液可能很困难。当没有合适的献血者样本可用， 并且必须使用患者样本时，必须获得知情同意。 采供血机构可能会规定，TTI 筛查为反应性的血液将被废弃，即确证试验可以不 做。在这些情况下，反应性可能是真的，也可能是假的，如果血液将被用于制备质评样 本，则可由EQA 项目提供者或指定的专家实验室进行确证。应尽量确保作为潜在质评 样本提供的血液在进行确证试验时被确证为阳性。这一点很重要，因为按照规定运输血 浆和进行确证试验均需要投入成本。如果血浆的反应性不如预期，那么这些投入就白费 了。 项目提供者可以采取的措施包括： ■ 寻找血浆时考虑献血者人群中的TTI 流行情况。优先考虑从特定TTI 流行率较 高的地区的采供血机构获取血浆，在这些地区，筛查试剂反应性结果的阳性预 测值较高。 ■ 选择具有良好质量体系的供应商，其试剂结果的质量可以信赖。 质评样本的供应商应根据其可靠提供所需样本数量和保证样本的质量的能力来选 择。EQA 项目提供方与供应商之间应签订正式协议，以确保质评样本的供应是可靠的， 并符合项目规定的所有规范。 即使参评实验室不需要对样本进行全面的检测（见 5.3 质评样本的选择），EQA项 目提供方或专家实验室（如果使用）能够准确对质评样本进行鉴定是非常有必要的。 用于TTI 质评活动的候选样本可以组织成一个“样本库”—— 一个具有不同特征的 数量庞大的大体积样本的存储库。建立样本库是可行的，因为针对TTI 检测，最常见的 质评样本是血浆或血清，它们可以被长期冷冻保存而不影响其血清学反应性。建立和维 持一个样本库需要大量和持续的资源。 4.5 建立样本库 应该在第一次EQA 活动开展之前就着手建立TTI 阳性血清或血浆的样本库，为质 评活动提供样本。应及时处理候选血清和血浆，并妥善保存。收到后，应为每个血清和 血浆分配一个唯一的实验室识别号。较大体积的候选血清或血浆应分装成多份较小体 积，以减少冻融循环次数。血清和血浆应在—20℃或以下冰冻保存在适当体积的聚丙烯 容器中。容器应带有防漏螺旋盖及密封装置，如O 形圈。 容器应使用高质量的胶粘标签清楚地贴上标签。应通过经验证的检测策略对质评样 本进行鉴定，以确定样本的真实血清学状态，以及存储在数据库中的信息（参见4.6 中 关于EQA 质评样本的鉴定和检测的内容）。 样本库的数据库是样本库中生物性材料的清单。清单中的信息应定期更新，因为每 23 次计划进行EQA 时都需要访问这些信息。 应记录在样本库数据库中的信息类型包括： ■ 唯一实验室识别号； ■ 参考号或代码； ■ 采集日期； ■ 接收日期； ■ 样本类型（如血清、血浆）； ■ 体积和小瓶数（如果分装成较小的体积）； ■ 临床信息和提供者的检测结果； ■ 鉴定试验结果； ■ 样本库中的冰箱位置； ■ 样本标签1 ； ■ 冰冻 /解冻循环次数。 一旦建立了样本库，建议继续分配资源，以持续保证未来EQA 活动所需的质评样 本的数量和体积。 4.6 制备候选质评样本 尽管血浆是TTI EQA活动合适的生物材料，但当将血浆用作EQA 样本时，必须 考虑到一些因素（如体积限制，无论是否有过滤或离心步骤仍会产生凝块）。在某些情 况下，去纤血浆或血清可被视为血浆的替代品。使用哪种生物性材料作为TTI EQA活 动的样本应考虑参评实验室的需要，以及TTI 检测方法中对生物材料的有效性规定。 可以进行处理以增加用于EQA 活动的生物材料的体积或质量。需要强调的是，EQA 样本应尽可能代表“正常”供者样本。每次处理都会导致样本偏离“正常”。而且，处理 可能对不同检测方法的结果产生不利影响。因此，在应用于EQA 活动的样本制备之 前，每种处理方法都应广泛验证其效果。 血浆转化为血清 在 采 血 袋 中 收 集 的 血 浆 含 有 抗 凝 剂 ， 如 枸 橼 酸 — 磷 酸 — 葡 萄 糖 （ citrate- phosphate- dextrose，CPD），因此无法自然转化为血清。然而，可以通过向血浆添加凝血 酶，人为启动凝血级联反应，然后去除产生的凝块，转化为去纤血浆（实际上是血 清）。一旦血凝块被清除，应考虑对血清进行微滤以清除任何细菌污染。2 1 考虑为每个血清或血浆分配一个“标签”或代码，有助于在数据库中搜索和识别样本。 2 Ratnoff OD.“An accelerating property of plasma for the coagulation of fibrinogen by thrombin”, Journal of Clinical Investigation. 1954; 33: 1175—1182. 24 过滤 生物材料可使用真空或压力过滤装置过滤，孔径逐步减小（预滤器，0.8μm、0.45μm和 最终0.22μm）。过滤将去除任何微粒物质，包括微小凝块和细菌。1 值得注意的是，血浆转化为血清和过滤过程烦琐费力，并有潜在的危险。因此，这 些过程应由人员在生物安全柜中进行，并配备足够的个人防护设备，包括白大褂、手套 和面罩或护目镜。 然而，必须尽可能提供没有污染、微粒物质和凝块的质评活动样本。通过离心来去 除颗粒物和凝块，就可以生产出令人满意的质评活动的样本，而不需要将血浆转化为血 清。在不进行过滤的情况下，为了保持无菌，质评活动的样本应放在二级生物安全柜中 处理。处理过程中应尽可能使用无菌设备和容器。 杀菌剂的使用 可考虑使用杀菌剂以降低细菌生长的可能性并保持生物材料的质量。杀菌剂的实例 为 ProClin 300（1.5% 甲基异噻唑啉酮、甲基氯异噻唑啉酮）。三氮化钠曾被广泛用作杀 菌剂，但出于安全考虑，不再推荐使用。应彻底验证任何杀菌剂，以确定对TTI 检测方 法的潜在干扰。2 混合样本 对于大型的EQA 项目，可以考虑将混合样本作为增加可用的质评活动样本量的 一种选择（参评实验室数量众多，对质评样本体积的要求超过了通常一袋血的体积）。 混合样本指将多个样本混合在一起。然而，在混合样本时，可能会产生稀释效应——换 句话说，每个样本的单个组分可能会被稀释。可通过选择具有相同抗体或抗原谱的样 本 （通过检测确定），从而仅混合具有相似检测结果或特征的样本来降低这种风险。混合有 利于扩大质评样本的体积，同时设法保持对混合样本中关键成分的反应性。有时，混合 阴性血清或血浆可造成假反应性趋势增加。因此，每次在投入EQA 活动使用之前， 应仔细检测混合的质评样本，无论其是阴性还是阳性。 稀释 尽可能避免用阴性血浆或其他等渗稀释液来稀释质评样本。只有在生物材料本身就 是被稀释的，而需额外增加体积时，才可以通过稀释该材料以增加体积。通过稀释的办 1 Bobbitt JA, Betts RP.“The removal of bacteria from solutions by membrane filtration”. Journal of Microbiological Methods. 1992; 16(3): 215—220. 2 ProClin: http://www.sigmaaldrich.com/content/dam/sigma-aldrich/docs/SAFC/General_Information/Proclin_efficacy. pdf. 25 法模拟早期感染情况或“弱反应性”检测结果来制备质评样本，其血清学特征不能代表 未被稀释的献血者样本。此外，某些检测方法检测被稀释的抗体或抗原的能力可能会降 低，而这些抗体或抗原在未被稀释时通常会被检测到。EQA 项目提供者必须采用可能 用于该质评项目的一系列的试剂盒检测被稀释的质评样本，以确保检测结果符合预期。 可量化的标记物——如乙型肝炎表面抗原（HBsAg）或HIV—1 p24 抗原的稀释可被 视为制备代表早期感染的血清学质评样本的备选方案，因为很难找到足够体积的天然生 物性材料。对于乙肝表面抗原作为标志物的情况，必须注意不要过度稀释其他早期乙肝 标志物（抗 HBcIgM），如果这些标志物同时也是EQA 项目正在评估的内容。 此外，稀释液必须不含乙型肝炎表面抗体，因为它很可能与HBsAg 形成复合物， 并使HBsAg 在检测系统中无法被检出。 干试管样本 交通条件是造成质评活动样本质量差的主要原因。此外，运输成本可能过高，给 EQA 项目增加了财政负担。 一些用于资源有限的条件下的EQA 项目提供干试管样本（dired tube samples，DTS），这 种DTS 样本指的是在空气中干燥12 ～24 小时的少量阳性或阴性血清或血浆。1 制备DTS 样本的时间内只能干燥少量体积（如20μl）的血清或血浆，但干燥后的 小球通常在磷酸盐缓冲盐水中以10 倍的体积进行溶解，从而得到稀释10 倍的质评样 本， 并且具有与一般血清或血浆样本不同的基质。不建议在DTS EQA 项目中使用弱阳 性样本，因为稀释可能导致所有或部分检测试剂盒出现假阴性反应。EQA 项目提供者必 须采用可能用于该质评项目的一系列试剂盒检测稀释的DTS 质评样本，以确保检测结果 符合预期。 尽管这些不同的方法违反了传统的EQA 规范，但是在传统EQA 项目不可行的情 况下，使用DTS 使得提供某种形式的质量监控成为可能。 必须注意的是，如果DTS 是作为EQA 项目的质评样本提供，则参评实验室必须在 检测前对其进行再溶解处理。这是一个附加变量，在分析和评分结果时必须考虑其潜在 影响。 EQA样本的鉴定与检测 TTI—EQA 中质评样本的关键属性： ■ 参评实验室使用的样本类型通常已经获得了试剂盒制造商的认可，如血清或血浆； ■ 质评样本具有均一性，在质评活动期间保持稳定； 1 Parekh BS, Anyanwu J, Patel H et al.“Dried tube specimens: a simple and cost- effective method for preparation of HIV proficiency testing panels and quality control materials for use in resource-limited settings”. Journal of Virological Methods. 2010; 163(2): 295—300. 26 ■ 质评样本中用于评估的标志物的真实状态是已知的。 随TTI 检测试剂盒一起提供的使用说明通常规定了适合在检测中使用的样本类型。 重要的是，EQA 项目中提供的质评样本应尽可能模拟所有检测允许的样本类型，否则， 如果质评样本类型与推荐的样本类型存在显著差异，则可能会获得异常结果。例如，如 前所述，在参评实验室使用的所有试剂盒中，EQA 项目提供者必须确认磷酸盐缓冲盐水 重新溶解的DTS 作为样本类型的适当性。 样本的鉴定通常是通过一套检测策略和一个明确定义的检测规则来实现的。检测策 略规定了用于确定样本状态的检测范围和类型；检测规则则具体规定了采用哪些检测方 法及其检测顺序。检测策略包括初检以识别阴性样本，以及随后的一个或多个补充试验 以确证初检呈反应性的样本是否为阳性。之所以需要开展反应性样本的确证试验，是因 为TTI 的所有检测都会有一小部分假阳性结果。再次检测有助于确保样本库中被指定为 阳性状态的样本是真正的阳性。 初检必须具有很高的灵敏度，特别是因为它将识别阴性样本，也就是说，初检的阴 性结果将被认为是正确的，并且在样本状态被录入样本库前，不会做其他试验来“确 证”样本的阴性状态。因此，项目提供者需要确信，用于鉴定样本库样本的初检试剂盒 的灵敏度达到了所要求的水平，并且检出的阴性样本不会被EQA 项目的参评实验室所 使用的其他试剂盒错误地检测为阳性。 EQA 项目提供者需要仔细考虑样本库样本的鉴定方式。例如，如果任何参评实验 室表明他们使用了检测HIV 抗体和HIV p24 抗原的HIV 联合检测试剂，则EQA 样本 必须针对这两种标记物进行鉴定。同样，如果参评实验室使用梅毒的特异性或非特异性 密螺旋体试验，则应了解EQA 样本的这两种标记物的状态。 选择用于样本鉴定和EQA 样本检测的检测方法时应考虑的关键因素是： ■ 检测方法的可用性：大多数国家都会有一个针对每一个标志物的可用试剂清单。 ■ 检测方法的特性：有关检测性能（灵敏度和特异性）、易用性、设备要求和其他 特性的信息是必要的。这些信息可在世界卫生组织网站1 上找到。同行评审的 出版物是另一个信息来源。 ■ 检测目的：EQA项目提供者可能除了鉴定EQA样本以外，还开展其他目的的检 测。正是由于这些不同目的的检测存在，才驱使了对检测方法进行选择，例如， 检测通量是多少，所需的周转时间是多长，试剂的保质期是多长，以及必要时 是否有冷藏条件等。 4.7 质评活动的文件 每次EQA 活动都需要随附文件，这些文件可能包括： 1 http://www.who.int/diagnostics_laboratory/evaluations/en/. 27 ■ 关于EQA样本如何处理、检测和报告结果的说明； ■ 结果表； ■ 反馈问卷，包括定期发出的使得项目能够持续改进的问卷。 每次EQA 活动的说明均应提供关于如何处理、检测和存储质评样本，以及如何向 EQA 项目提供者报告结果的一般信息。应提醒参评实验室将质评样本视为常规样本， 并对其进行相同的检测和处理流程。说明书通常包括以下信息： ■ 质评样本的编号和标识符； ■ 质评活动代码； ■ 提交结果的截止日期； ■ 储存和处理说明； ■ 检测说明； ■ 报告说明； ■ 生物安全预防措施； ■ 项目提供方联系信息。 附录3 给出了质评活动说明的示例。 EQA 项目提供者应准备一份表格，以收集EQA 活动的结果。EQA 结果表可以电 子形式或纸质形式提供。无论使用哪种形式，该表格都将允许采用标准化方法从参评实 验室收集EQA 活动的结果和信息。 纸质数据收集方式要求EQA 项目提供者设计一份结果收集表，并与样本盘一起发 送给参评实验室。完成检测后，实验室必须通过邮件或传真将填好的结果表提交给EQA 项目提供者。这种收集方式易于建立，并允许参评实验室灵活地提供信息。纸质数据收 集的一个缺点是所有参评实验室的结果都必须由EQA 项目提供者整理，这一过程既耗 时又容易出错。 电子数据收集形式可通过电子方式发送给参评实验室。当质评活动的检测工作完成 后，参评实验室将结果输入表格中，并可以通过电子方式将其提交给EQA 项目提供者。 EQA 项目提供者可以通过电子方式复制和整理数据，减少数据输入所需的时间。尽管这 种形式可以降低数据输入错误的可能性，但验证检查是必要的，以确保数据被准确复 制。 电子数据收集的更进一步的形式是基于互联网的方式。这种方法需要设计和维护一 个在线数据采集系统。参评实验室可以将EQA 活动的检测结果直接输入在线数据库。在 这种形式下，EQA 项目提供者不需要输入数据，从而节省这一步所需的时间和消除了可 能出现的错误。这种数据收集形式的一个缺点是需要资源来设计和维护一个功能强大的 网站。此外，参评实验室需要有信息技术基础设施来使用该系统。 无论选择哪种方式收集EQA 活动的检测结果，结果表通常应包括以下信息： ■ 参评实验室的代码和名称； 28 ■ 收到质评样本的接收日期和状态； ■ 所用检测方法或试剂的名称； ■ 试剂批号和有效期； ■ 检测日期和检测人员姓名； ■ 检测结果和判读； ■ 其他要求。 质评活动检测结果表的示例见附录4。 4.8 物流 根据当地的基础设施，EQA 项目组织者需要决定将EQA 样本盘运送到参评实验 室的运输方式。应考虑可能接触到质评样本的所有工作人员群体的健康和安全问题，包 括邮政和快递工人。这些人必须接受培训，如果包装损坏或有泄漏，应当如何安全地处 理质评样本。EQA 样本应按照当地或国际邮政或航空条例，例如，国际航空运输协会 （international air transport authority，IATA）的规定，进行包装和贴标签。根据IATA 的 规定，质评样本可以作为诊断样品运输，而不是作为危险物品运输。 IATA 的规定明确要求三层包装和标签。简言之，装有质评样本的小瓶密封在一 个防水的第二层包装内，该包装内含有足够的吸水材料，以防发生泄漏或破损时吸收包 装内的全部质评样本。第二层包装应放置在能够保护内容物在运输过程中免受物理损坏 的最外层包装中（图 3）。 防水盖子 吸水性材料 第二层包装 发送 /接收实验室信息 第一层包装容器 内容物目录 硬质外包装 相关的货物名称 包装标签 来源 图3. 符合国际航空运输协会（IATA）标准的诊断样品运输三层包装示意图 外包装应贴上标签，表明其含有病理物质。EQA 项目的名称和地址，以及接收质 评样本的参评实验室的名称和地址，均应写在外包装上。 29 5. TTI检测EQA项目的计划和实施 需要两种类型的计划来指导准备EQA 项目。一是年度计划，描述项目的主要特点 和项目提供者在一年中的质评活动。另一个计划是详细说明从质评样本制备开始到最后 出具EQA 报告所要进行的工作。每次EQA 活动都需要这类计划。 5.1 制定年度EQA计划 在EQA 项目开始之前，项目提供者应确定并规划年度EQA 的流程。计划应形成 文件被记录，并包含针对EQA 项目一年各次活动的目标和设计的信息。年度计划应包 含一些参考资料，如标准操作规程、流程和其他更详细信息的文件。 通常，EQA 年度计划应包含以下信息： ■ EQA提供者的名称、地址和联系方式； ■ 参与EQA项目的供应商的名称、地址和联系方式（如果适用）； ■ 年度EQA 项目的任何具体目标——例如，年度目标可以是检查实验室在不同 场合检测相同样本时获得重复性结果的能力； ■ 确保样本库中的样本足以满足年度质评活动的需求； ■ 预期可被招募参加EQA项目的参评实验室的数量和类型； ■ 参评费用或资助机制； ■ 参评实验室在每次 EQA活动中需鉴别、测量或检测的样本和分析物的 有关信息； ■ EQA样本的制备、质量控制、存储、分发的要求； ■ EQA样本制备、发放给参评实验室的时间表和日期，参评实验室提交结果的截 止日期； ■ 均一性和稳定性检测的程序； ■ 所用统计方法的描述，参评实验室能力评价标准； ■ 参考结果和最终报告提供给参评实验室的预计日期。 5.2 制定具体的EQA活动计划 虽然年度EQA 项目计划作为高级别文件描述了项目的总体情况，但每次EQA 活 动的筹备工作需要一个具体的计划来指导。这个更具体的计划将记录如何执行每个单独 的质评活动。 具体计划应说明以下每次质评活动的信息： ■ 每个工作人员在质评活动准备中的责任； ■ 活动的目的； 30 ■ 参与活动的实验室数量； ■ 满足活动目的的每个样本的选择标准和需要量； ■ 活动名称、样本盘编号和代码； ■ 每个质评样本的标识； ■ 详细的制备流程和鉴定检测； ■ EQA样本制备、发放给参评实验室的时间表和日期，参评实验室提交结果以及报告 发布的截止日期； ■ 针对每次活动的均一性和稳定性的具体流程； ■ 涉及质评活动的所有文件、表单和记录。 建议在制定具体的EQA 活动计划的同时，设计一份进程检查表和时间表；这将确 保过程发生的系统性，并提供了整个EQA 过程的可追溯性。 5.3 EQA样本的选择 应从样本库中选择满足特定EQA 活动目标的适当样本。根据样本库数据库中记 录的定性检测结果，每次质评活动应包含最高质量的样本，每个样本都有明确的血清学 状态（见 4. 建立EQA 项目时实际考虑因素）。 EQA 活动的样本通常包含若干阴性和阳性样本。阴性和阳性样本的数量及其在 样本盘中的摆放顺序在每次质评活动中都应不同，以避免参评实验室预测质评活动样本 的组成。 应准备足够的分装成小瓶的样本，以同时满足参评实验室的需求和项目提供 者储存备用的要求。如果参评实验室因丢失或破损而需要更换样本，或者在出现 错误后需要重复检测，则需要项目提供者提供备用的分装样本。在整个质评活 动期间， 基于稳定性、存档或未来使用的目的，项目提供者还需要额外的分装 样本用于内部检测。 每份质评样本所需的总体积通过考虑以下因素来计算： ■ 质评活动参评实验室的总数； ■ 需准备额外样本盘的数量（用作更换或调查目的）； ■ 每次质评活动中，均一性和稳定性检测所需的分装样本数量； ■ 每个分装样本所需的体积； ■ 样本盘生产（经离心和分装）过程中允许的体积损失或误差。 5.4 EQA样本的准备 从样本库中取出被确定了的合适样本，同时在样本库的数据库中也应更新样本状 态。 样本在使用前需要解冻。对于较小体积的样本，血浆可以在30 ～ 37℃的水浴中解 31 冻（一般不超过30分钟）。解冻时间因水浴温度和血浆体积而异1。如果样本储存在多个 小瓶中，一旦解冻，应合并相同的样本。如果在EQA 活动中使用混合的样本，混合 过程将在这一阶段进行。 同一样本的单独分装的小样或用于混合的不同样本的分装小样在做进一步处理之前 必须充分混匀。 将每个样本全部体积离心以沉淀颗粒物质，并将上清液倒入单独的无菌瓶中。每个 样本在分装到单独的小瓶中以制备质评样本之前，都应再次进行检测，并与原始样本库 定性结果进行交叉核对，以验证没有混淆、且在存储期间没有降解。如果有结果与预期 不同，则该样本不适合用于本次质评活动，建议选择其他替代样本。 5.5 EQA样本的分装 应选择适当容量的有外螺纹旋盖的聚丙烯样品管分装样本，并在分装前预先贴上黏 性标签。黏性标签应经过验证，以证明其在波动的温度和储存条件下始终黏附于样品管 上。样品管上的黏性标签应包含以下信息： ■ EQA项目名称； ■ 质评活动编号或代码； ■ 样本标识； ■ 样品管中所含样本的体积。 建议尽可能以电子方式打印标签上的信息，以尽量减少抄写错误。每次质评活动所 有样品管的贴签应分开进行以避免贴好标签的不同样品管的混淆。 在准备下一个质评样本之前，应完成前一个质评样本所有样品管的分装操作，以降 低污染、样本混淆或分配到不正确样品瓶的风险。建议先分配阴性样本，然后分配阳性 样本。生物样本的操作最好在生物安全柜内进行。 一旦质评样本被分装到样品管中，样本盘就可以放入贴有标签的包装中。包装标签 应包含以下信息： ■ EQA项目名称； ■ 质评活动编号或代码； ■ 样本盘中的样本数； ■ 建议储存温度； ■ 有效期； ■ 生物危害标识。 准备分发前，组装好的样本盘应储存在2 ～ 8℃之间，分发应在制备完成后 尽快进行。 1 Extended life plasma: a framework for preparation, storage and use, 2nd edition. Australian and New Zealand Society of Blood Transfusion Ltd; 2013. 32 5.6 验证均一性和稳定性 无论使用何种生物样本，都必须确保质评样本得到充分混匀，所有参评实验室都获 得成分均匀、差异最小的相同样本（均一性样本）。样本的均一性试验应在每次EQA 活 动的样本分发前完成。均一性试验应当： ■ 检测随机选择的具有代表性数量的分装样本； ■ 在质评样本制备并分装到样品管中之后，且在发送到参评实验室之前。 选出的用于均一性试验的分装样本数量应足以评估质评样本的可能偏差。对于已分 装的每个质评样本，随机选择适当数量的样品管。ISO 17043指出：“在适当情况下，提 供者或者供应商应使用从一批质评样本中随机抽取的具有代表性数量的样本进行统计， 以评估样本的均一性。”均一性试验所需的样品管数量没有明确的规定，但作为参考， 通 常选择至少10%或 10个样品管，以较大者为准。然而，选择用于均一性试验的样品管 数量不应超过单次检测时的可检测的最大样本数，以避免检测批次间的偏差。 确保样本的反应性在任何被选出的和检测均一性的样品管中没有变化很重要。必须 执行广泛的均一性检测方案，并记录所有文件。对于均一性试验，建议使用EQA 项目 提供者样本验证策略中相应标志物的初检方法。如果单个样品管中样本的检测没有产生 预期的结果，可能会导致包含该质评样本的所有样品管从质评活动中移除。附录5 中包 含了均一性试验方案的示例。 5.7 稳定性验证 有必要验证样本的稳定性，以确保样本在到达参评实验室时适于使用，并且没有发 生样本完整性的损坏。温度、时间、生物样本类型、病原体特性和其他因素都会导致样 本完整性的丧失。样本的稳定性可以通过不同的机制来验证： ■ 在室温下，将样品管保持在未开封的状态，保持时间为预计质评样本分发到参 评实验室的时间长度，然后重新检测以确认反应性； ■ 在实验室不同温度下进行加速稳定性研究； ■ 模拟实时稳定性研究。 稳定性检测方案的准备和实施将监控和评估质评样本的可能降解率。从EQA 活动 的样本制备完成之时到至少活动结束之日，应监控质评样本的稳定性。 选择用于稳定性试验的样品管数量应足够，以便在整个质评活动期间定期进行检 测。如果发生降解，定期监测将有助于确定降解的时间。建议在质评活动结束后的短时 间内继续监控稳定性，以防止可能出现的任何问题。 与均一性试验一样，建议选用EQA 项目提供者的样本验证策略中相应标志物的初 检方法进行稳定性试验。稳定性试验开始前，文件化的检测方案需要被拟定，并考虑质 评活动的时间安排和可能影响质评样本稳定性的因素。接受标准也必须记录在稳定性检 33 测方案中，并规定如果检测结果显示质评样本的稳定性已经发生变化时所应采取的措 施。在制定接受标准时，允许稳定性分析结果检测批内和检测批间的变异是很重要的。 附录6 中包含了稳定性试验方案的示例。 将样本发送到一个或多个远距离的参评实验室，然后返回进行重新检测，有时也用 于稳定性试验。然而，这只能验证样本在运输过程中的稳定性，除非样本在参评实验室 保存至整个质评活动结束再返回。 5.8 包装和分发 相关特定EQA 活动的文件应放置在包装内。包括处理质评样本的说明和记录结 果的表格（如果使用纸质结果表格）。虽然该文件的模板在项目开始时已制定，但在分 发前对所有文件进行校对和检查是很有必要的，以确保信息中没有矛盾、模糊或遗漏， 并且信息与正在分发的质评样本相对应。随附文件应密封在保护袋中，并贴在第二层包 装的外面。 如果EQA 项目提供者决定使用电子结果表格，则应在发送质评样本的同时，通过 电子邮件将这些表格发送给参评实验室。 包装质评样本时列出参评实验室的注册编号有助于确保没有实验室遗漏。制定 包装规程也很重要，包括检查每个参评实验室被包装的质评样本和文件的组合是否正确。 附录7 是一个质评样品发放和提交结果的记录示例，可用作打包检查表。如果所有的工作 都在一天内完成，只需注明日期，并在每个参评实验室的“文件包装”“样本包装”和“样本 分发”栏中打钩即可。如果包装后，在其他日期发送质评样本至参评实验室的，则应分别记录包装和分发 的日期。 5.9 EQA结果的收集和截止日期 参评实验室应在指定的结果提交截止日期前向EQA 项目提供者提交填好的检测结 果表。在此时间后收到的结果不应被接受，特别是稳定性试验的时间长度没有超过截止 日期时。为了鼓励和提醒参评实验室，EQA 项目提供者可在截止日期前一周联系参评 实验室，提醒参评实验室提交其结果。 EQA 项目提供者收到填好的结果表后，应加盖日期戳，并以便于检索的方式存档。 EQA 项目提供者可以选择对收到的结果表格进行快速审查，以确保表格已经填好，所有 信息清晰可辨，没有重大错误。 5.10 EQA结果的整理 应以有利于分析的方式整理参评实验室的EQA 结果。整理EQA 结果的方法取决于 如何收集数据和提交数据的类型。 EQA 结果的整理应在一处安全并保密的固定场所进行。虽然手工整理结果是可行 34 的，但是最好使用电子系统，以便于存储和分析。至关重要的是，EQA 项目提供者应 当有一个数据质量管理过程。基于手工系统需要更高水平的管理，以尽量减少数据 抄写和输入中的错误。数据处理的次数也应该减少以避免错误。对于手工和电子的 结果整理方法，均需要安全的数据存储和记录维护（包括电子数据的充足备份）。 在设计整理和分析系统时，需要考虑参评实验室提交的一种或多种检测方法的检测结 果类型（定性或定量）。是否需要每条支持信息（如检测方法名称、批号、有效期、操作 者、检测日期等）都包括在内，取决于分析数据的方式。 5.11 分析EQA结果 为了分析EQA 结果，每个质评样本的参考结果需要由EQA 项目提供者确定。该 参考结果通常会根据EQA 样本制作过程中进行的鉴定试验来确定。然而，参考结果偶 尔可能会根据一组实验室的一致结果来确定。理想情况下，质评样本出现与鉴定结果有 偏差的非预期结果的情况很少发生。应向参评实验室清楚说明参考结果。 EQA 结果分析的复杂性可能取决于： ■ EQA项目的成熟度和EQA项目提供者的专业知识； ■ EQA活动的目的； ■ EQA项目提供者可用的资源。 另一个重要的考虑因素是向参评实验室提供反馈和报告的时间表。在EQA 活动中 及时交流实验室的性能水平可能比需要较长时间才能完成的深入分析更有用。 简单的分析EQA 结果的方法应重点关注： ■ 报告结果与参考结果不同的参评实验室； ■ 检测结果与参考结果不同的检测方法。 进一步深入分析EQA结果的方法可以包 括： ■ 通过将相同检测方法的检测数据组成子集的方法来调查各种检测方法的性能； ■ 调查参评实验室使用的不同试剂批号的性能； ■ 使用统计工具分析定量结果。 每个参评实验室都应收到一份对其在质评活动中的性能水平的单独分析。单个实验 室的报告应明确强调参评实验室报告的任何与EQA 项目提供者确定的参考值不同的结 果。重要的是要记住，为了保密，在报告或评估参评实验室的性能水平时，只能使用实 验室代码。 在分析数据集或使用统计工具时，要意识到在少量结果之间进行比较可能是无效 的。 5.12 EQA结果的统计分析 可以对定量结果进行统计分析，以确定参评实验室的某个检测结果是否存在显著性差 35 异。要执行这种类型的分析，必须将数据划分为相似的组，以便分析的数据集所包含的结果仅 来自相同的检测方法（同类分析组）。有必要删除离群结果，这些结果可能会使数据集的均数和 标准差发生偏离。识别异常结果的统计方法包括Grubbs 检验和Tukey 检验。1 汇总统计可以描述数据集的均数、标准差和变异系数。该信息提供“目标”值，并 允许参评实验室将其性能水平与其他使用相同检测方法的实验室进行比较。EQA 项目 提供者应考虑到，当数据集中的结果数少于5 个时，生成的统计资料可能无法准确表示 该检测方法中样本的预期结果。因此，对于小型数据集，报告统计分析结果无用且不合 适。 稳健统计（ robust statistics）通常也用于分析EQA 对应分组的结果，并被 ISO 13528 ：2005《实验室间比对能力验证的统计方法》所推荐使用。 5.13 EQA报告的编制 质评活动中对提交的数据进行分析的结果应记录在报告中，并提供给所有参评实验 室。为了维护参评实验室的保密性，报告中应仅使用代码。这样，可以在不违反保密性 的前提下，传达有关参评实验室之间总体检测质量的信息。 尽可能缩短向参评实验室提供EQA 活动分析报告所需时间是优先事项。 EQA 活动反映了每个参评实验室在特定时间点的检测能力。对实验室问题的及时 反馈使参评实验室可以对任何发现的缺陷进行调查并采取必要的纠正措施。对性能情况 反馈时间的延误可能会降低对检测结果进行全面分析的价值。在EQA 项目提供者无法 作出及时反馈的情况下，参评实验室可以接受另一种程序，即在质评活动结束后立即发 送初步报告，随后再发送最终报告。 5.14 初步报告 初步报告总结了当次EQA 活动中样本的组成。它不包含任何结果分析，因此可以 预先准备。初步报告应包含： ■ EQA活动的名称、日期和代码； ■ 样本鉴定试验的结果； ■ 每份质评样本的参考值。 初步报告中的信息使参评实验室能够迅速查看其在质评活动中的表现，并在必要时 采取纠正措施。 5.15 最终报告 EQA 活动的报告应包含以下信息： 1 Barnett V, Lewis T. Outliers in statistical data, 3rd edition. Wiley; 1994. Tukey’s filter: http://www.statisticshowto.com/ tukey-iqr-test/. 36 ■ EQA项目提供者的名称和联系方式； ■ EQA活动的名称和代码； ■ 对 EQA活动中提供样本的描述，包括制备方法和如何获得参考值； ■ 每种质评样本的鉴定试验结果； ■ EQA活动的目的； ■ 介绍使用的数据分析方法； ■ 参加当次质评活动的实验室数量； ■ 对参评实验室的结果进行单独评估，突出显示那些与参考值不同的结果。 此外，以下信息可以提高EQA项目的价值： ■ 按使用的检测方法分类的每种质评样本的结果总结； ■ 与参评实验室使用的特定检测方法或试剂批号有关的系统性问题； ■ 向参评实验室提供有关如何解决实验室错误的建议； ■ 对质评活动结果的总体评价和讨论。 需要注意EQA 活动报告应清晰和信息丰富。建立可以形成报告的基础模板可确 保每次质评活动传递信息的一致性，并提高报告编写过程的效率。EQA 项目提供者 对提交的质评活动结果所做出的评论和建议应该是客观、建设性和循证的。当可以推断 出错误原因时，EQA 活动的报告可以提出预防措施的意见和建议。根据EQA 活动中 检测到的错误类型、频率和严重性，项目提供者可能会选择采取其他措施来帮助参评实 验室纠正其检测流程（请参阅6. 实验室性能监控、结果反馈和教育）。附录8 提供了 初步报告和分析的示例，这些示例可包含在EQA 活动的最终报告中。 5.16 参与证书 参加EQA 项目是实验室质量管理体系的重要组成部分。因此，实验室可能需要证 明这种参与及其性能水平的证据。尽管EQA 报告和在EQA 中发现错误后采取纠正措 施的证明是最好的证据，但许多参评实验室也可能要求提供参与证书。 颁发年度参与证书，详细说明所参加的质评活动次数，可以成为鼓励参评实验室继 续参与的积极手段。 参与证书可以通过多种方式颁发。例如，可以在每次EQA 项目的活动开展后或每年 颁发证书。EQA 提供者将需要定义什么构成“参与”。可以在不考虑检测性能水平的基础上， 授予参加EQA 的证书，也可以基于达到最低性能水平来授予证书。无论哪种情况， EQA 项目提供者都应预先确定最低参与或性能水平，并将这些要求告知参评实验室。 6.实验室性能监控、结果反馈和教育 性能监控包括制定可接受的性能标准，并确定未能达到这些标准的参评实验室。 37 EQA 项目识别不合格操作的目的是提供建议和支持，以帮助这些实验室提高检测性能 水平。 EQA 在现有国家质量体系中的定位将决定是否需要监控个体实验室的性能，以及 在性能水平持续不佳的情况下采取适当的纠正和预防措施。 6.1 设定可接受的性能标准 性能监控的第一步是定义合格、不合格以及可能的处于“边界”的性能标准。在定 义可接受的性能标准时，必须考虑错误的潜在临床意义。因此，在建立EQA 项目时， 建议在规定的期限（如一年）内运行该计划，并按如下所述对错误进行初步跟进，但不 要进行正式的性能监控或评分。在这段时间内，可以收集每种检测方法当前性能水平的 信息，如TTI 的快速检测性能或试剂盒性能。这个过程将有助于设立实际可完成的、可 接受的性能标准，同时确保将主要错误（例如TTI 的假阴性结果）定义为不合格。 对于性能监控，尽管由于技术问题或流程错误（如结果的错误抄录或检测样本 的调换）导致的错误结果可能会分别进行分析和报告，但这些错误结果之间没有区 别。无论造成错误的原因为何，输血实验室或医院血库中的错误结果都可能造成同 样严重的后果。因此，建议根据结果判读，而不是根据每次检测的血清学反应性记 录，来进行性能监测和数值评分（如果使用）。除了不正确的结果外，不提交结果或延 迟提交结果也属于性能不合格。 性能标准应由顾问委员会独立商定，该委员会包括参评实验室代表和该领域的专 家。顾问委员会还应负责定期审查性能不合格的定义，并在必要时进行更改以反映总体 性能的改善。 6.2 性能监控的数值评分系统 可以开发评分系统以监控各个实验室的性能。尽管这样的评分系统可以客观地显示 正在取得的进展，但是评分可能有一个缺点，即实验室由于担心得不到足够的分数而会 相互商量结果或“作弊”。这种行为严重限制了EQA 项目的参与价值。对于EQA 项目 提供者而言，重要的是向参评实验室的员工、主管和负责人强调非惩罚性方法对EQA 性能的重要性。 使用罚分的评分系统最容易权衡临床意义，并且最容易使用累计分数来发现不合格 的操作。评分可以“加权”以反映所犯错误的潜在临床意义。评分系统应预先确定，并 作为EQA 项目资料手册的一部分传达给参评实验室。 累积分数可用于发现持续的不合格操作以及处在“边界”水平的实验室。建立系统 后，应在每次质评活动报告中给出累积分数。如果无法做到这一点，则可以在年度总结 中为每个实验室提供累积分数，以显示每个实验室的性能趋势。 性能监控的数值评分系统示例见附录9。 38 6.3 不合格操作的跟踪 EQA 项目的任何后续行动均应遵守顾问委员会制定的流程。虽然EQA 项目有执行 后续行动的职责，但这些干预措施的程度应记录在案，并与EQA 项目提供者的可用资 源保持一致。例如，EQA 提供者可以进行初步联系，以确定可能的错误原因并提供建 议。 如果EQA 项目提供者的干预措施无法使实验室性能水平随之提高，则应致函实验室 负责人以报告情况，提供正式建议并提出可能的解决方案。应制定程序以确保一旦实验 室表现不佳，就可以监控其过程，直到获得一致的令人满意的性能水平。项目人员应该 对水平不合格作出客观判断和提供建设性建议。提供的任何建议均应以证据为基础， 并 与国家标准或指南（如有）相符。 严重错误的示例包括任何标记物的假阴性结果或多个假阳性结果，未能识别出故意 的笔误或样本混淆。持续帮助的选项可能包括： ■ 提供有关改进机会的具体、长期和周期性的建议； ■ 提供其他EQA样本以进行故障排除； ■ 提供实验室实习培训； ■ 促进参评实验室的监督访问或审核以找出缺陷，包括与实验室负责人进行沟通。 项目提供者开展上述活动的能力将取决于分配给他们的资源。顾问委员会应大力主 张提供这些资源，因为只有在这些支持活动得以开展时，才能最大限度地发挥EQA 项 目的益处。 每年应对参评实验室的性能水平进行纵向审查。这将确保从一个EQA 活动到另一 个EQA 活动，始终存在问题的参评实验室可以得到充分跟进。为了帮助监控参评实验 室的性能，EQA 项目提供者可以选择将参评实验室的性能日志记录在日志本或电子表 格中，以便于审核。 6.4 自我评估 如果没有EQA 项目的任何性能监控或跟进，则将个体实验室的结果与其他实验室 的结果进行比较是强调改进需求的有用手段。此过程通常可以在没有外部干预的情况下 提高标准。 6.5 教育 EQA 项目的主要目的是提高性能水平并提供协助以解决所发现的任何问题。因此， 教育功能在EQA 项目的所有活动中是固有的。它可以单独提供给实验室，也可以提供给 所有参评实验室和其他相关专业人员。 与个体参评实验室在EQA 活动中所犯的错误相关的内容具有特别重要的教育作用。 39 如果有可用资源，EQA 项目人员可以帮助实验室确定错误的根本原因，并为实验室操 作和程序的更改提出建议，以防止其再次发生。EQA 活动中的错误可能是由于特定的 技术问题所致；但是，明显的简单错误（例如，抄录错误导致TTI 结果记录不正确）可 能表明实验室质量体系存在更广泛的问题和不足。 项目可以通过出具不同检测技术和方法的整体性能报告来提供更广泛的教育，这些 报告提供了有关良好实践的具体学习要点。项目一旦建立，就有可能在顾问委员会的帮 助下组织年度科学会议或研讨会，供参评实验室解决EQA 活动中所强调的问题。 如有可能，项目提供者应以在地方、国家和国际会议上展示和发行出版物的方式交 流，这种方式不仅能将项目产生的信息传达给参评实验室，而且还能传达给更多的听 众。EQA 项目数据还可以用作编写和修订指南的基础，使输血领域的所有工作人员都 可以接受教育。 7. EQA项目的监测和评估 为了使EQA 项目取得进展，定期监测其发展并评估其影响非常重要。评估还将提 供客观证据，以支持该计划的继续进行，并且对于其可持续性至关重要。评估应至少每 年进行一次，并形成报告。 7.1 指标 下面列出了可用于评估项目成功与否的过程和成果指标。但是，应该认识到，与成 果指标有关的改进可能受到与参加EQA 项目没有直接关系的因素的影响，如引入更好 的试剂或技术。 过程和输出指标 每年要收集的过程和输出指标的示例包括： ■ 顾问委员会会议频率和出席人数； ■ 参评实验室的比例； ■ 每次质评活动中，提交结果的实验室所占的比例，以及迟报、未报结果的 实验室所占的比例； ■ 注册需要进行额外检测来评估结果的实验室数量； ■ 记录与项目运行有关问题的数量； ■ 投诉数量以及解决了的投诉数量； ■ 质评样本不符合文件要求的次数； ■ 参评实验室的积极反馈； ■ 问题解决和教育； 40 ■ 项目出版物发表或会议展示。 成果指标 成果指标的示例包括： ■ 合格和不合格的性能比例； ■ 总分的改变（如果适用）； ■ 在几次质评活动中使用相同样本的性能趋势； ■ 参评实验室使用的检测方面的改进或变更； ■ 参评实验室获得认证。 7.2 影响 通过分析结果，可以确定项目在一段时间内产生的影响。例如，通过合格与不合格 的性能比例或总分的变化，可以推断出献血者样本错误检测结果的减少程度，从而将传 播风险降到最低。检测操作的改进可以转化为节省成本和技术人员时间。当利益相关方 和项目资金提供方了解到这些影响时，继续为项目提供资金就变得理所当然。 7.3 年度报告 应编制项目年度报告，并分发给利益相关方，包括卫生行政部门，顾问委员会和其 他有关方面，例如参评实验室。其内容可能包括： ■ 质评样本分发情况总结； ■ 参评实验室总体性能总结，突出任何趋势性变化； ■ 过程指标总结； ■ 质评活动中的学习要点； ■ 项目内在的发展详情和挑战； ■ 对项目影响的总体评估； ■ 人力和财力资源（如适用）。 41 术 语 本术语表采用ISO9000 ：2006《质量管理体系：基础和词汇》或ISO 15189 ：2013 《医学实验室：质量和能力要求》中的定义编制。如果这些标准中有定义，则提供了参 考文件。斜体定义旨在定义本文档中相关单词或短语的用法以及各术语之间的关系。 标本（specimen）: 为检验、研究或分析一种或多种量或特性而取出的，认为可 代表全部的独立部分的体液、呼出气、毛发或组织等（ISO 15189 ：2013）。 标志物（marker）: EQA 项目中包含的质评样本的具体特性，如HIV 抗体、HIV 抗原、梅毒螺旋体抗体。 标准操作规程（standard operating procedure）: 执行记录、实施和维护活动或过 程的具体方法。 管理体系（management system）: 建立质量方针和质量目标并实现这些目标的 体系（ISO 9000 ：2006）。 过程（process）: 将输入转化为输出的一组相互关联或相互作用的活动 （ISO 9000 ：2006）。 检测（test）: 按照程序确定一个或多个特性（ISO 9000 ：2006）。 流程（procedure）: 为进行某项活动或过程的具体方法（ISO 9000 ：2006）。 能力（competence）: 展示出对知识和技能应用的才能（ISO 9000 ：2006）。 能力评估（competency assessment）: 评估个人应用知识和技能的能力的过程。 确认（validation）: 通过提供客观证据对特定的预期用途或应用要求已得到满足 的认定（ISO 9000 ：2006）。 认可（accreditation）: 权威机构对一个组织有能力执行特定工作给出正式承认 的过程（ISO 15189 ：2013）。 审核（audit）: 为获得证据并进行客观评价，以确定满足审核准则的程度所进行 的系统的、独立的并形成文件的过程（ISO 9000 ：2006）。 室间质量评价（external quality assessment，EQA）: 使用已知、保密的样本对实 验室操作进行外部评估，并与其他实验室的操作进行比较。 室间质量评价项目（external quality assessment programme）: 由认可机构组织的 正式项目，可以是地方的项目或由国家、区域或国际机构组织。 室内质量控制（internal quality control）: 验证达到预期质量结果的程序，可能包 42 括监控日常检测结果的重复性和发现分析过程中的主要错误（ISO15189 ：2013）。 文件（documentation）: 与提供的产品或服务有关的书面制度、操作指南和记录。 血液安全监测（haemovigilance）: 监测、报告和调查与所有输血活动有关的不良 事件。 样本（sample）: 作为潜在质评活动的样本的标本，最好是大容量，并经处理、检 测后贮存于样本库。 样本盘（panel）: 一套EQA 质评样本。 有效性（effectiveness）: 策划的活动被实现的程度及策划的结果被获得的程度 （ISO 9000 ：2006）。 质量（quality）: 一组固有特征满足要求的程度（ISO 9000 ：2006）。 质量管理（quality management）: 在质量方面指挥和控制组织的协调的活动 （ISO 9000 ：2006）。 质 评 活 动 的 样 本 （exercise materials）: 从 标 本 中 制 备 并 组 成 EQA 样 本 盘 的 样本。 43 附 录 以下附录作为参考示例供希望成为EQA 项目提供者的机构使用。这些例子根据具 体情况适当修改后，可以作为设计项目和编写文件的基础。 （1） 参评实验室初步调查问卷 （2） 室间质量评价登记表 （3） 质评活动说明 （4） 质评活动结果表 （5） 质评样本均一性试验方案 （6） 质评样本的稳定性试验方案 （7） 质评样本分发和结果提交的记录 （8） 质评活动分析和报告 （9） 数值评分系统 44 附录 1 参评实验室初步调查问卷 对捐献血液进行输血传播感染（TTI）筛查的室间质量评价（EQA）项目 请填写以下有关您实验室中输血传播感染筛查和一般质量措施的调查问卷。 第一部分 联系方式 机构名称 ： 联系人姓名 ： 部门 ： 地址 ： 电话 ： 传真 ： 电子邮箱 ： 第二部分 实验室信息 1. 员工数量： 2. 每年处理的标本数量： 献血者 其他（请注明） 3. 请说明您实验室中进行的TTI筛查类别和使用的检测方法 您的实验室使 用的TTI 筛查 您想要开展的 室间质量评价 项目 艾滋病 毒 丙型肝 炎病毒 乙型肝 炎病毒 强制筛检* 梅毒 美洲锥 虫病 人类T 细 胞白血 疟疾 病病毒 Ⅰ /Ⅱ型 * 国家规定的筛查。 45 标志物 你们实验室 使用的检测试剂 盒 名称 检测试 剂盒生产商 名称 仪器设备 所需的量 （ml） 包括重 复试验和死体积 使用的检测方法 4. 每次进行检测是否包括独立的（非试剂盒质控品）室内质控（IQC）品？ 是 否 如果是，是否会随时间记录和监控这些室内质控的表现？ 是 否 5. 你们实验室有微型离心机吗？ 是 否 如果是，它运行时的最小和最大转速是多少？ 6. 你们实验室有冰箱吗？ 是 否 第三部分 室间质量评价方案偏好 每个样本盘有多少样本？ 1 ～ 3 5 10 每年开展多少次质评活 动？ 1 2 3 总体评价 ： 46 附录2 室间质量评价登记表 机构名称 ： 联系人姓名 ： 部门 ： 邮寄地址 ： 配送地址 ： 电话 ： 传真 ： 电子邮箱 ： 如有需要，可以获得报告的其他联系人 ： 电子邮箱 ： 请指明您的实验室希望参加的室间质量评价项目。每次质评活动包括五个质评样 本。每年参加两次质评活动被认为是最低可接受的水平。 活动编号 艾滋病毒 丙型肝炎 病毒 乙型肝炎 病毒 梅毒 美洲锥虫 病 人类T 细 胞白血 疟疾 病病毒 Ⅰ /Ⅱ型 1 2 3 47 附录 3 质评活动说明 预期用途 这是一组带编码的用于质评活动的样本，每个质评样本中（样本盘所评估的标志 物）的反应性为已知状态。本研究的目的是评估开展常规血液TTI 筛查的实验室的性 能。 提供的样本 ■ X（插入数字）管血清样本，每管Y（插入体积），标记为：1A、1B…… ■ 结果表。 质评样本储存，处理和检测说明 ■ 涡旋混匀，然后在检测之前离心所有质评样本。 ■ 将质评样本与常规献血者标本一起处理，并按照你们实验室通常处理的方式处理。 ■ 警告：质评样本具有潜在的传染性，应使用普遍的安全预防措施进行处理。 ■ 整个质评过程中样本应储存在2 ～8℃。 质评样本的检测说明 ■ 使用实验室中使用的检测策略，以常规献血者标本常用的检测方式检测质评样本。 填写结果表的说明 ■ 请在您可以选择答复的地方打钩。 ■ 每页仅报告一个检测试剂盒的结果。复印相关页面用于报告其他检测试剂盒的结果。 ■ 缩略语的定义：（示例） — R ：反应性； — N ：阴性； — INC ：不确定。 提交结果的说明 ■ 确保在截止日期之前提交结果。 48 附录4 质评活动结果表 质评活动识别代码 ：01/04（示例） 实验室注册码 ： 联系人姓名 ： 机构名称 ： 电话号码 ： 电子邮件 ： 实验室收到样本盘的日期 ： 收到的样本是否完好？ 是 否 评论 ： （如果收到的样本盘的状态不正常，可以通过以下详细信息与室间质量评价项目 提供者联系来更换样本盘）。 编号为“01/04”的质评活动截止日期为×× 年×× 月×× 日 请将填妥的结果表格反馈至（插入室间质量评价项目提供者的详细信息）： 室间质量评价项目提供者 ： 室间质量评价项目联系人姓名 ： 地址 ： 电话 ： 传真 ： 49 电子邮件 ： 质评结果表：酶免疫分析法 质评活动01/04 实验室注册码 检测试剂盒名称： 第一轮 检测操作 者： 检测日期 ： 试剂盒批号 ： 试剂盒有效日期 ： 第二轮 检测操作 者： 检测日期 ： 试剂盒批号 ： 试剂盒有效日期 ： 主管 ： 结果 质 评样本 编号 检测样本的吸光度 / 临界值（S/Co）比值 （第一轮） 检测样本的S/Co（吸光度/ 临界值） 比值 （第二轮） 检测试剂盒的结果 判读 吸 光度 （ A） 临 界值 （ B） S/ Co 比 值 （ A÷ B ） 吸光度 （A） 临 界值 （ B） S/Co比 值 （A÷B ） 复 孔1 复 孔2 复 孔1 复 孔2 1 A R N INC 1 B R N INC … … R N INC … … R N INC 1 X R N INC 评论： 结果报告的操作者名字： 50 质评结果表：快速检测法 项目名称 /ID ： 参评实验室代码 ： 试剂盒批号 ： 试剂盒的有效期 ： 操作者姓名首字母 ： 质 评样本 标识 检 测日 期 第一个判读者 第二个判读者 最 终 结 果判读 C 判 读者编 号 a 抗 体条 / 带b 抗 原条 / 带b 质 控条 / 带b 判 读者编 号 a 抗 体条 / 带b 抗 原条 / 带b 质 控条 / 带b a 首字母缩写。 b 阴性，阳性，不适用（N/A）。 c 阴性，反应性，无效。 51 附录 5 质评样本均一性试验方案 ■ 例如，代码为“01/04”的质评样本盘包含5 个编号为“1A、1B、1C、1D 和 1E” 的质评样本。 ■ 在制备过程中，每种质评样本制备分装了80管。 ■ 从每种EQA样本中选择10管代表性的小样（参考下面的方法选择）进行均一性检测。 ■ 使用随机数发生器生成10 个随机数字（样品管编号），记录被选择用于均一性检 测的 10 个样品管编号（如 15 号、25 号、31 号、47 号、58号、66号、70 号、80 号、12 号、22号小瓶）。 ■ 从每种质评样本中挑出相同号码的小样。 ■ 所选的小样需要用新的均一性检测代码重新编号，以确保检测过程中的可追溯性 （如 1A ：H1、1A ：H2………1A ：H10 等）。 ■ 在 2 ～8℃下存放小样以进行均一性检测，直到执行检测为止。 ■ 在相同的检测过程中，使用适当的检测试剂盒对每个小样进行一次检测。 ■ 如果发现任何质评样本的结果与参考结果不同，则必须重复检测两次。该质评样本 的最终检测判读将取决于三次检测结果的一致性。在适当的表格中记录结果（请参 见下表）。 ■ 处置前，将均一性检测的小样保存在2 ～8℃下，直到均一性检测结果被EQA 项 目提供者审核并接受。 ■ 接受标准：如果每个小样的所有检测结果判读均与参考结果相符，则应接受将该 质评样本纳入样本盘。 52 示例：代码为“01/04”的质评样本盘的均一性试验结果 质评样 本： 1A 1B 1C 1D 1E 参考结 果： 反应 性 阴性 阴性 反应 性 反应性 H1 反应 性 阴性 阴性 反应 性 反应性 H2 反应 性 阴性 阴性 反应 性 反应性 H3 反应 性 阴性 阴性 反应 性 反应性 H4 反应 性 阴性 阴性 反应 性 反应性 H5 反应 性 阴性 阴性 阴性 * 反应性 H6 反应 性 阴性 阴性 反应 性 反应性 H7 反应 性 阴性 阴性 反应 性 反应性 H8 反应 性 阴性 阴性 反应 性 反应性 接受情 况： 通过 通过 通过 失败 * 通过 *双孔重复检测。该质评样本的最终检测结果判读将取决于三次检测结果的一致性。 53 附录 6 质评样本的稳定性试验方案 ■ 示例：01/04样本盘包括5个质评样本，分别标记为1A、1B、1 C、1D 和 1E。 ■ 制备质评样本并将每种质评样本分装成80 管小样，其中包括从每种质评样本中挑 出进行稳定性试验的6管小样。 ■ 挑出的小样需要用新的稳定性代码重新编号，以确保检测过程中的可追溯性（如 1A: S1，1A: S2，1A: S3，1A: S4，1A: S5和 1A ：S6）。 ■ 确定质评样本在质评活动期间所暴露的时间和温度条件。 举例 ：样本盘经历的活动及计划表 代码 :质评活动样本 1A 01/04 ■ 在将样本盘送往参评实验室之前，将进行稳定性试验的小样贮存在2 ～8℃的环境中 活 动 计划 时间 质评 样本 贮存温度 条件 制备后 第0 天 2 ～ 8℃ 开始发放 第4 天 S1 37℃ 结束发放 第11 天 S2 37℃ 质评活动开始日期 第12 天 S3 2 ～ 8℃ 质评活动中间日期 第25 天 S4 2 ～ 8℃ 质评活动截止日期 第32 天 S5 2 ～ 8℃ 截止日期后的7 天贮存期 第39 天 S6 2 ～ 8℃ 4 天。在第4 天取出稳定性试验的小样1A: S1，用适当的检测试剂盒检测分析物。 ■ 将剩下的5个稳定性试验小样移至37℃ ±1℃并存放7天。 ■ 于第11天取出稳定性试验小样1A: S2，用适当的检测试剂盒检测标记物。 ■ 将其余4个稳定性试验小样移至2 ～8 ℃存放。用适当的检测试剂盒检测下列小样 中的分析物: — 1A: S3 第18 天； — 1A: S4 第25 天； — 1A: S5 第32 天； — 1A: S6 第39天。 ■ 任何质评样本的结果与参考结果不同，必须重复检测两次。该质评样本的最终结果 判读将取决于三次检测结果的一致性。在适当的表格中记录结果（见下文）。 54 ■ 接受标准：稳定性的标准应基于不稳定性对参评实验室的结果不确定性的影响， 进而对参评实验室的结果可接受性影响的评估。 55 举例 ：样本盘稳定性试验结果 代码 : 01/04 质评样 本： 1A 1B 1D 1E 参考结 果： 反应性 阴性 反应性 反应性 S1 反应性 阴性 反应性 反应性 S2 反应性 阴性 反应性 反应性 S3 反应性 阴性 反应性 反应性 S4 反应性 阴性 反应性 阴性* S5 反应性 阴性 反应性 阴性* S6 反应性 阴性 反应性 阴性* 接受情 况： 稳定 稳定 稳定 不稳定 *双孔重复测试。该质评样本的最终检测结果判读将取决于三次检测结果的一致性。 56 附录 7 质评样本分发和结果提交的记录 样本盘代码： 实验室 代码 文件装 箱 样本装 箱 质评样本 分发 结果收 到 说 明 0001 0002 0003 0004 0005 0006 0007 0008 0009 0010 0011 0012 0013 0014 0015 0016 0017 0018 0019 0020 0021 0022 0023 0024 57 附录 8 质评活动的分析和报告 初步报告 样 本编 号 * 样本 类型 说明 抗 HIV—1 状态 p2 4 参考 结果 1 血浆 阴 性 阴 性 2 混合血浆 阳 性 阴 性 3 混合血浆 阳 性 阴 性 4 混合血浆 阴 性 阴 性 5 混合血浆 阳 性 阴 性 6 血浆 阴 性 阴 性 7 用人类阴性血浆稀释 HIV—1 培养上清液 样品中含有 0 ～ 5 000 pg/mL 的 B 亚型细胞培养上清 阴 性 阳 性 8 血浆 阴 性 阴 性 9 混合血浆 阳 性 阴 性 1 0 血浆 阴 性 阴 性 *标识代码。 58 包含抗 HIV 的 EQA 样本盘中的样本特 征 Bio- Rad Bio- Rad Genetic Systems HIV—1 Ag 确认试 验 HIV—1 免疫 印迹 p 24 参考 结果 Mure x Geneti c 样 本 HIV— 1.2.O System s 抗 HIV— 编 号 Ag/Ab EIA （S/Co* ） HIV—1 Ag** EIA （S/Co ） p18 p 24 p 31 p 34 gp4 1 p53 p68 实 验结 果 判读 1 状 态 1 0.41 0.20 未检测 未检测 不适 用 阴性 阴性 2 14.96 0.24 未检测 - + + - + ++ ++ +++ 阳性 阳性 阴 性 3 15.21 0.21 未检测 - + ++ - + + +++ +++ +++ 阳性 阳性 阴 性 4 0.48 0.25 未检测 未检测 不适 用 阴性 阴性 5 18.82 0.24 未检测 +++ + ++ + + + + +++ +++ +++ 阳性 阳性 阴 性 6 0.39 0.25 未检测 未检测 不适 用 阴性 阴性 7 0.31 40.66 37.83 未检测 不适 用 阴性 阳性 8 0.37 0.26 未检测 未检测 不适 用 阴性 阴性 59 9 18.57 0.25 未检测 ++ + ++ + + + + +++ +++ +++ 阳性 阳性 阴 性 1 0 0.41 0.20 未检测 未检测 不适 用 阴性 阴性 * 检测样本OD 值：临界值，S/Co≥ 1 为阳性。 ** 抗原。 60 含最终质评报告的分析 标志物假阴性和假阳性结果的百分比 假阳性 % 假阴性 % 梅毒 0 0 0 0 TND = 100 TPD = 28 HIV 10 9.80 0 0 TND = 102 TPD = 68 抗HTLV—Ⅰ /Ⅱ 0 0 0 0 TND = 56 TPD = 19 HCV 0 0 0 0 TND = 85 TPD = 26 HBsAg 0 0 2 7.1 TND = 90 TPD = 28 合计 10 2.2 2 1.1 TND = 448 TPD = 175 TND = 阴性样本测定总数。 TPD = 阳性样本测定总数。 参评实验室各标志物检测操作 参 评实验 室代码 HIV HBs Ag 梅毒 HCV 抗 HTLV— Ⅰ / Ⅱ 1 A A A A A 2 A A A A — 3 A A A A A 4 A A A A A 5 A A A A A 6 A A A A A 7 A A A A A 8 A A A A A 9 A A A A — 10 A A A A — 11 B2 A A A A 12 B2 A A A A 13 B2 A A A — 14 A C A A — 61 A=100% 符合。 B1= 存在假阳性报告（≤参评实验室样本测定总数的5%）。 B2= 存在假阳性报告（＞参评实验室样本测定总数的5%）。 C= 假阴性结果。 —= 未开展。 62 每个质评样本报告的假阳性和假阴性结果（%） 样本编号 % 假阳性 % 假阴性 试剂盒分析 下面的示例表显示了参评实验室所使用的每种梅毒检测试剂盒的错误结果数量，类 似表格可以用于其他标志物。 检测试剂盒 F PR % T ND F NR % T PD Architect 梅毒 检测方法 0 0 3 0 0 0 9 Murex ICE 梅 毒检测方法 0 0 1 5 0 0 3 Macrovue RPR 卡 0 0 1 0 0 0 2 Trepanostika 重 组TP 检测方法 0 0 1 0 0 0 5 总数 0 0 6 5 0 0 1 9 TND = 阴性样本测定总 数。TPD = 阳性样本测定 总数。FPR = 假阳性结果。 FNR = 假阴性结果。 63 附录 9 数值评分系统 最简单的评分方法只评估每种质评样本的最终状态，总分为100% EQA样本盘代码 年份 得 分 预期结 果 阳 性 阴 性 阴 性 阳 性 阳 性 样本编 号 1 2 3 4 5 参评实 验室结果 阳 性 阴 性 阴 性 阴 性 阳 性 8 0% 检测结果和最终结果判读的评分方法 EQA样本盘代码 年份 参评实验室 结果 样本 编号（预 期结果） 试剂 盒1 试剂 盒2 试剂 盒3 最终 结果 得 分 1（阴 性） 非反 应性 未检 测 未检 测 阴性 2/2* 或 20 2（阳 性） 反应 性 反应 性 非反 应性 阳性 3/4 或 15 3（阳 性） 反应 性 反应 性 反应 性 阳性 4/4 或 20 4（阴 性） 反应 性 非反 应性 非反 应性 不确 定 2/4 或 10 5（阳 性） 反应 性 反应 性 反应 性 阳性 4/4 或 20 总分 85% 满分=100 分，每个质评样本20 分。每个质评样本最多四个结果。 * 得最高分：两个答案均正确（试剂盒2和 3无需检测样本1）。 64 检测结果、最终解释及后续检测规则的评分方法 EQA样本盘代码 年份 参评实验室 结果 得 分 样本编号 （预期结 果） 试剂 盒1 试剂 盒2 试剂 盒3 最终 结果 检测结 果 （80% ） 检测策 略 （20% ） 1（阴 性） 非反 应性 非反 应性 非反 应性 阴性 16/1 6 0/4* 2（阳 性） 反应 性 反应 性 非反 应性 阳性 12/1 6 4/4 3（阳 性） 反应 性 反应 性 反应 性 阳性 16/1 6 4/4 4（阴 性） 反应 性 非反 应性 非反 应性 不确 定 8/16 4/4 5（阳 性） 反应 性 反应 性 反应 性 阳性 16/1 6 4/4 总分 84% 满分=100 分，每个质评样本20 分。每个质评样本最多四个结果，每个结果得4 分，如果遵循检测规则，则得4 分。 * 尽管试剂盒1 得出样本1 为阴性结果，但参评实验室继续用试剂盒2 和3 进行检测，因此该检测规则不得分。 按标志物来评价检测性能的一致性 ： 室间质量评价方案——样本盘编号 ： 参评实验室编号： 梅毒 HIV HTLV HCV HBsAg A A A A A 符合标准： A 结果100% 正确，无假阳性和假阴性结果。 B1 存在假阳性报告（≤参评实验室样品检测总数的5%）。 B2 存在假阳性报告（＞参评实验室样品检测总数的5%）。C 存在假阴性报告。 65 208 世界卫生组织促进血液安全文件精选