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Q&A column, 1/17

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Editor: Frederick L. Kiechle, MD, PhD

Submit your pathology-related question for reply by appropriate medical consultants. CAP TODAY will make every effort to answer all relevant questions. However, those questions that are not of general interest may not receive a reply. For your question to be considered, you must include your name and address; this information will be omitted if your question is published in CAP TODAY.

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Q. I have a technologist who is a recent graduate from a medical technology school. She has her BA but the school she attended did not offer an internship program. We are offering her one year of on-the-job training so she will be able to sit for her ASCP certification exam after completing the one year of training. The question is related to her desire to work alone on the midnight shift, especially in the blood bank. Does she have to complete the training before being allowed to work alone per regulations? Or can we allow her to do so based on our confidence level in her abilities?

A. The CAP Laboratory Accreditation Program checklist requirements address the training and qualifications needed to perform patient testing. Most blood bank testing includes the performance of high-complexity testing. For a recent graduate to qualify to perform high-complexity testing with a bachelor’s degree, the employee’s personnel records must show that the degree is in a chemical, physical, biological, or clinical laboratory science or in medical technology from an accredited institution. If the diploma is listed as a bachelor of arts degree without the field of study, transcripts are needed to further evaluate the qualifications for equivalence. The checklist requirements do not specifically require personnel certification or completion of a medical technology internship. However, there are requirements for testing personnel to successfully complete initial training to perform their assigned duties and demonstrate proper test performance prior to starting patient testing, as well as requirements for competency assessment at least semiannually during the first year of patient testing.

The laboratory director and transfusion service medical director are responsible for determining the duties the individual will perform and the level of supervision needed. They must also ensure that proper supervision is in place and available as needed. It is essential that a technologist working alone have the proper experience and judgment to take appropriate steps and understand when to consult with the director or a supervisor. Permitting employees to work without direct supervision is left to the discretion and judgment of the laboratory director and transfusion medicine director, who must take into consideration the scope of testing performed, the workload, and the level of expertise required for the patient care environment (e.g., level one trauma center).

Lyn Wielgos, MT(ASCP), Checklist Editor, CAP Accreditation Programs, College of American Pathologists, Northfield, Ill.

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Q. Defects in coagulation are often hard to detect. In my 27 years in the clinical laboratory, I’ve found most physicians do not know how to address serious coagulation issues. What education is being provided in this area?

A. The CAP Coagulation Resource Committee agrees that up-to-date educational resources in the area of coagulation laboratory testing are important and therefore has undertaken a variety of educational initiatives. First, the second edition of the CAP Press book An Algorithmic Approach to Hemostasis Testing, edited by Kandice Kottke-Marchant, MD, PhD, and with contributions from former and current members of the Coagulation Resource Committee, has been extensively revised and updated. Several new chapters address topics such as quality and consultation in hemostasis testing, and updated information on newly available anticoagulant and antiplatelet agents is included.

Next, the Coagulation Resource Committee provides educational content distributed through the CAP Coagulation, Limited proficiency test (C mailing). The committee develops annual educational activities for CE credit on such topics as preanalytic variables, quantitative D-dimer measurement for evaluation of venous thromboembolism, and the effect of direct oral anticoagulants on hemostasis testing. Another educational initiative in association with the Coagulation, Limited Survey is the dry lab challenge (A mailing), which asks laboratories to evaluate common but challenging case scenarios that arise in the hemostasis laboratory (such as sample handling, preanalytic, and data interpretation issues). Discussion of the correct dry lab challenge answers along with pertinent references is provided in the participant summary report.

The committee regularly proposes educational sessions for presentation at the CAP annual meeting and other laboratory professional meetings on hot topics in hemostasis laboratory practice. The focus of an educational session at the 2012 CAP annual meeting was direct oral anticoagulants, thrombophilia consultation, and difficult topics in hemostasis (D-dimer, establishing an APTT therapeutic range, and analytical measurement range). Educational sessions in 2013 and 2014 were on von Willebrand disease, rapid emergency hemorrhage testing, and consultative reports in coagulation. In response to the new analytical measurement range CAP checklist requirement in the coagulation section, a CAP Coagulation Resource Committee member presented on the topic of AMR for coagulation at the 2013, 2014, and 2015 annual AACC meetings.

The committee also presented in 2013 a CAP webinar on point-of-care testing for coagulation. More recently, the CAP sent representatives to the FDA workshops on direct oral anticoagulants (2015) and point-of-care PT/INR testing for monitoring warfarin (2016). Future educational initiatives from the committee will include research articles sharing valuable experience gained from CAP proficiency testing results.

Kottke-Marchant K, ed. An Algorithmic Approach to Hemostasis Testing. 2nd ed. Northfield, Ill: CAP Press; 2016.

Karen Moser, MD, Assistant Professor, Pathology, Department of Pathology, Saint Louis (Mo.) University, School of Medicine, Member, CAP Coagulation, Resource Committee

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Q. A question arose in our group as to when to call a margin positive in a radical prostatectomy specimen. If only perineural tumor invasion is present at an inked margin, is that considered evidence that the resection margin is involved?

A. If tumor extends to the ink even if the only site is with perineural invasion, it should still be considered a focal positive margin. In the posterolateral region in the neurovascular bundle, perineural invasion is one of the major mechanisms by which prostate cancer extends out of the prostate.

Jonathan I. Epstein, MD, Professor, Departments of Pathology, Urology, and Oncology, Reinhard Professor of Urologic Pathology, Johns Hopkins Medical Institutions, Director, Surgical Pathology, Johns Hopkins Hospital, Baltimore

Dr. Kiechle is a consultant, clinical pathology, Cooper City, Fla. Use the reader service card to submit your inquiries, or address them to Sherrie Rice, CAP TODAY, 325 Wau­ke­gan Road, Northfield, IL 60093; srice@cap.org. Those questions that are of general interest will be answered.

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