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<div class="h1_sec"><h1>Quality control in the new environment: QC materials;

an ideal control closely simulates patient specimens, is stable, and

comes in large homogeneous lots.</h1><div class="h1_sec_details"><div><span class="">By </span>Lawson, Noel S.<br />Publication: <a href="/medical-laboratory-observer/41391-1.html" title="Medical Laboratory Observer" relatedarticles="false" id="41391" 
		
		
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Medical Laboratory Observer</a>

<br /><span class="">Date: </span><span class=""><a href="/medical-laboratory-observer/19870101/2987041-1.html" title="Medical Laboratory Observer: 19870101" relatedarticles="false" id="2987041" 
		
		
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Thursday, January 1 1987</a>

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<div class="KonaBody"><div class="article_bod" style="margin-top: 45px;"><div class="article_bod" style="overflow:auto; padding-left: 25px;"><P>Quality control in the new environment: QC materials

</P><P>  Process control is the cornerstone of a total quality assurance

program.  Intenral process control consists of activities undertaken

during the analytic process and is directed principally toward assessing

the acceptability of patient data.  External process control, through

surveys arising from outside the laboratory, tests a lab's ability

to obtain the correct result on an unknown specimen.

</P><P>  In internal process control, specimens that have known

concentrations are inserted into the analytic run.  These control

specimens serve as tools for assessing the degree to which a given

analytic run represents previous runs in control.  The database obtained

from internal quality control testing is used to evaluate patient data

during analytic runs in progress; to quantitate analytic variation at

clinically useful concentration levels; and to facilitate

interlaboratory comparison of performance for accuracy and precision,

through a regional database.

</P><P>  The proficiency surveys in external process control are typically

sponsored by professional organizations or governmental agencies. They

are used both for quality control and as an evaluation mechanism for

accreditation and/or licensure.

</P><P>  Extended internal (or regional) quality control programs also draw

widespread participation in the United States.  Large numbers of labs

work on common pools of control materials.  Comparison of results gives

participants information on their accuracy, as measured by distance from

target means, and relative precision. These measurements aid in lab

self-evaluation and peer review.

</P><P>  Successful programs for internal and external process control rest

on such components as analytic processes, control materials, and data

handling resources.  The central role played by control materials is

critical to the success of the total quality assurance effort.  Although

internal quality control may be practiced without control

materials--through patient-derived statistics, for example--by far the

most widely used and effective methods are based on the control sample

technique.

</P><P>  External, internal, and regional quality control programs place

important demands on quality control materials.  These materials should

mimic the unknown specimens being analyzed as much as possible.

Ideally, they will be homogeneous and stable, and contain matrix and

analytes in a concentration similar to that of patient specimens.  They

should also be available in large lots with minimal vial-to-vial

variability.

</P><P>  An ideal material for chemistry would be fresh stable liquid human

serum with no additives, in unlimited quantities.  Since this material

cannot exist, it is evident that we must make certain compromises in

selecting materials for quality control.

</P><P>  Procedures such as lyophilization, freezing, and osmotic

manipulation are necessary to render control materials stable.  A high

degree of homogeneity between vials is critical for validating

quantitation of statistical quality control parameters, both within and

between laboratories.  Excessive inhomogeneity increases the apparent

imprecision of an individual laboratory's data as well as grouped

interlaboratory performance data in surveys and regional programs.

</P><P>  The concentration of analytes in the control material should be at

or near the concentration of the unknown specimens.  Since this is not

practical for all specimens, controls are generally employed at or near

clinically relevant decision levels.

</P><P>  In chemistry, two levels of controls, containing a wide variety of

analytes, are most commonly used.  Typical levels, for example, might be

8.5 and 10.5 mg/dl for calcium and 130 and 150 mEq/L for sodium.  With

enzymes, such as CK, LD, and transaminases, values at the upper limit of

normal and at two to three times the upper limit of normal are

frequently employed.

</P><P>  Control materials today are almost all prepared commercially, most

commonly using plasma obtained by plasmapheresis.  When these materials

are available in large lot sizes, such as chemistry pools of 1,000 to

2,000 liters, there is enough for many laboratories to share common

pools and an interlaboratory database for expanded internal (regional)

quality control.

</P><P>  Two to four hundred laboratories may share regional pools for a

year or more, with the average laboratory using approximately 4 to 8

liters per level annually.  In external quality control programs,

controls are usually circulated by mail and analyzed over a short period

of time--for example, one or two days.  Thousands of labs may share

these pools, with each requiring a maximum volume of only a few ml per

challenge.

</P><P>  Homogeneity in control materials is necessary to attribute

variation in analytic data correctly to the analytic system.  A lack of

homogeneity may result from incomplete mixing of pools or from

differential stability of unstable analytes within portions of a pool.

Inhomogeneity is not considered to be a significant problem with pools

produced within the last decade.

</P><P>  Variability in lyophilized controls can also be traced to

lyophilization and reconstitution procedures.  This variability may

derive from differences in vial fill volumes, in the amounts of residual

moisture in lyophilized dplugs, and in the quantities of reconstitution

fluid employed at the bench.  If the manufacturer and the analyst are

careful, the contribution of these factors to total analytic variation

will be negligible.

</P><P>  In addition, if variation in analyte concentration, such as drift,

is to be attributed corectly to the analytic process, the constituents

in control materials must remain stable for as long as the pools are in

use.  Considerable work has been performed to characterize the stability

of analytes in quality control materials.  Most analytes are stable in

the common matrices employed, but in various lots, instability of

several analytes has been documented.

</P><P>  For practical purposes, it is wise to recalculate quality control

target values and limits during the life of the quality control pools,

rather than rely on fixed limits determined at an early stage of use.

This minimizes the number of false error signals wrongly attributed to

the analytic process instead of stability-related changes in analyte

concentration.

</P><P>  An often overlooked feature of quality control materials is their

commutability, or interchangeability with patient

specimens--specifically, the applicability of data derived from controls

to patient specimens.  This is affected to a great degree by the

composition of the background matrix in which analytes are dissolved and

suspended.  Since all quality control materials are subjected to

stabilization procedures, as well as various other manufacturing

processes, they are rendered dissimilar to fresh human specimens in

varying degrees.

</P><P>  The applicability of data from quality control procedures to

clinically relevant measurements varies by analyte, method, and matrix.

There are documented differences in the behavior of nonhuman and liquid

controls relative to lyophilized human serum. Analysts must understand

the extent to which controls fail to detect analytically and/or

clinically significant errors.

</P><P>  Since the mid-1950s, clinical labs have benefited from a major

technologic improvement: Manufacturers began producing large lots of

homogeneous control materials in lyophilized or freeze-dried form. This

freed laboratories from the need to prepare their own control materials

from banked blood or pooled leftover serum.  These procedures had

yielded controls with significant instability, frequent hepatitis B

contamination, and variable target values.

</P><P>  Although early pools of lyophilized quality control materials

reflected advanced technology, instability was found among certain

analytes.  Significant deterioration in glucose concentration and

decreased activity of various enzymes, particularly CK, were noticeable

problems.  Major improvements in stabilization, mass freeze drying, and

final filtration have essentially resolved these problems.

</P><P>  The control sample method is widely applied to internal quality

control in clinical chemistry, cellular hematology, and coagulation.  In

chemistry, quality control materials are available for routine analytes,

enzymes, blood gas studies, ligand assay, and therapeutic drugs.

Commonly used chemistry QC products are derived from human or animal

(primarily bovine) serum.  These materials are stabilized either by

freeze-dry or powder-dry lyophilization or by osmotic manipulation using

ethylene glycol additive.

</P><P>  Cellular hematology products largely use a human red cell base,

supplemented by a variety of particulate additives--for example, avian

cells or synthetics simulating leukocytes or platelets. Coagulation

controls are produced from donor plasma manipulated to adjust the

concentration of coagulation factors.

</P><P>  Lyophilization accomplishes stabilization by reducing the residual

aqueous medium to less than 1 per cent and by allowing low temperature

storage with a neglible effect on analytes.  In traditional freeze-dry

lyophilization, vials containing aliquotted serum are frozen and

subsequently subjected to vacuum dehydration. Gradual heating removes

the rest of the moisture.

</P><P>  A relatively recent process utilizes powder drying.  Control

materials are flash frozen by spraying fine particles into cold gas at

subzero temperatures.  Vacuum drying follows, and stirring keeps the

mixture of fine dry particles or "beads" homogeneous.  The

resulting product has higher optical clarity than traditionally

lyophilized materials because there is less denaturation of lipoprotein.

The College of American Pathologists' survey program for clinical

chemistry uses these products.

</P><P>  A variety of agents have been employed to reconstitute lyophilized

materials.  These include distilled water and buffers with ammonium or

TRIS cation and carbonate or bicarbonate anion.  Sodium bicarbonate, a

common reconstituting agent, offers the advantages of containing a

noninterfering physiologic cation and being adjustable to provide two

clinically useful bicarbonate levels.

</P><P>  Osmotic manipulation can also achieve stabilization.  When freezing

points are lowered, controls can be stored as a liquid at freezer

temperatures.  One widely used control contains approximately 30 per

cent ethylene glycol as an osmotic agent.

</P><P>  To obtain clinically suitable analyte concentrations, manufacturers

of control material must dilute base materials and/or add various

constituents during preparation.  With inorganic analytes and most

organic analytes, pure materials are easily obtained for addition.  With

protein analytes, peptides, and enzymes, however, the process becomes

more complex because additive materials of human origin are not always

readily available.

</P><P>  Since controls should simulate patient specimens as much as

possible, it is desirable that animal additives also react as closely as

possible to their human counterparts.  Particular problems are posed

when antigenic, immunochemical, or binding properties vary between human

and nonhuman protein or peptide additives.

</P><P>  Moreover, differences in enzyme activity related to isoenzyme and

species differences may be significant.  Enzyme additives are generally

most satisfactory when they are of human origin and derived from the

isoenzymes predominant in human serum.  Practical considerations

preclude obtaining human additives for many enzymes, but such additives

are available and widely used for aspartate aminotransferase, acid

phosphatase, and amylase.

</P><P>  Several quality control products have been employed for blood gas

analysis.  They are commercially prepared by adjusting acidity to

simulate acidotic, alkalotic, and normal specimens.  The pO.sub.2 and

pCO.sub.2 are adjusted as well to include clinically representative

values.  The matrices used include aqueous buffer, hemolyzed and whole

blood, and fluorocarbon.

</P><P>  Significant vial-to-vial variation in these measurements occurs

when the temperature is not controlled carefully, or when opened vials

are not assayed rapidly, allowing equilibration of specimens with room

air.  Unlike blood- or protein-based products, aqueousbased blood gas

controls lack the sensitivity to detect membrane coating by protein.  In

addition, protein-based controls are sensitive to temperature changes

that do not noticeably affect aqueous materials.

</P><P>  A variety of assays have been shown to be superior when human

control material is used.  These include procedures to measure protein

and peptide analytes when protein binding is an important factor.  Human

material is demonstrably better than nonhuman for quality control in

numerous methods of measuring total iron binding capacity, bilirubin,

thyroxine, and albumin.

</P><P>  Among the cited disadvantages of human control material are its

cost (generally, it is slightly more expensive than nonhuman products),

its limited availability (one must rely on donor centers rather than

abattoirs), and the potential transmission of such infectious agents as

hepatitis.  Most products are screened for hepatitis B reactivity and

HIV and appropriately labeled following manufacture.

</P><P>  The advantages frequently cited for controls of animal source are

increased clarity over human materials when lyophilized, wider

availability, and lower price.

</P><P>  With respect to liquid verus lyophilized matrix, liquid materials

are relatively simple to use, possess good stability, and produce less

waste--open vials can be recooled for use on subsequent days. Major

disadvantages of ethylene-glycol-based material are its significant lack

of commutability for various procedures and limitations on its use with

certain analyzers.

</P><P>  For instance, the material is not suitable for quality control of

osmolality because of the high ethylene glycol content.  In addition,

the relatively high viscosity causes liquid controls to behave

differently from fresh or lyophilized materials in analyzers where fine

tubing conducts the sample.  Futhermore, these controls have limited use

with film-based reagent systems because of the interaction of ethylene

glycol with support material.

</P><P>  Lyophilized control materials vary in vial-to-vial filling volume

by less than 1 per cent.  Products are membrane-filtered, resulting in

negligible bacterial counts.  They maintain a moisture content of less

than 1 per cent by weight.  Disadvantages are the necessary

reconstitution and the alteration of analyte concentrations during

lyophilization.  Alterations include loss of CO.sub.2; an increase in

pH; denaturation of very low-density lipoprotein (VLDL), which causes

increased turbidity; and slight changes in viscosity and osmolatiy.

</P><P>  Turbidity in lyophilized materials is attributable to denaturated

lipoprotein.  Lyophilization by the quick freeze-powder fill techniques,

as