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The interpretations below are provided by Donna Castellone, MS, MT (ASCP) SH for Aniara Diagnostica.

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Do you remember the anticipation that came with a holiday? Any holiday at all- the excitement of what would come, whether it was being off from school or getting together with family and friends and if you were lucky enough, the giving and receiving of a gift! The older you get the less all of that seems important, but the reality is that everyone has a wish or a want or a need. So, what would you like to unwrap for your coagulation laboratory this season? Here would be my list… and I have been really good, so I would expect at least a few would be granted!

Present #1: Trained staff compensated for their worth: Coagulation staff are a special commodity. They need to be able to perform high complexity testing and have strong insight as to what to look for with patient results. It takes a very long time to fully train and retain staff, they should be compensated for all of their extra effort, learning and problem solving that is required. It would be wonderful if laboratories could recognize those skills.

Present #2: A year of passed proficiency testing and inspections: Everyone makes mistakes or can overlook an expired reagent, but wouldn't it be wonderful to have one of those perfect years. Totally possible. The trick is to invest in your quality. Make it a part of your daily routine and make everyone responsible for contributing to this, or you will not survive. A quality manager is wonderful and is responsible for overseeing and implementing processes and responding to errors, but if good coagulation processes are put in place, training and competency is in place and everyone is responsible for quality in the coagulation laboratory, this present should be under the tree.

Present #3: Understanding your reagents and how tests perform. Do you understand how your routine coagulation reagents perform? Are they insensitive to certain factors - meaning will there be a normal screening test, despite having an abnormal factor level? Or are your reagents supersensitive- meaning a prolonged screening test, despite a normal factor assay level - it happens. Think of the downstream effect - cost of extra testing, or increased length of stay due to testing, or having patients needlessly see specialists due to results? What about understanding when a test result reflects a change in patient status - if a protein C result goes from a 55% to a 60% is the patient improving or is that essentially the same number? What is the coefficient of variation for that test? Lupus testing, that DRVVT, was sufficient lot to lot testing performed? Is that borderline result ratio of 1.2 now a positive? Have you tested patients and not only controls. Investing time in this process will yield way more beneficial outcomes. It's the gift that keeps on giving!

Present #4: If the elves could deliver longer expiration dating or better sequestering of lots, that would be amazing. Just think of the cost savings of not having to perform lot to lot validations. A timely task and you can use a lot of reagent performing these validations. I realize that manufacturer's can't extend expiration dates - but if laboratories could learn to better utilize/predict annual use that would be most helpful. Creating a realistic approach to reagent utilization can ensure optimization of usage and minimizing waste due to reagents expiring. Coagulation testing is very expensive, taking the time to review how the laboratory tests can really improve budgets and save time. This doesn't not preclude residents learning about a test (HIT) and ordering it on every patient with a decrease in platelets!

Present 5: Understand Choosing Wisely! This initiative is led by the ABIM (American Board of Internal Medicine) Foundation. For Hematology ASH has developed evidence-based recommendations to determine necessity and potential harm of procedures. Also, the initiative works to eliminate costly overuse of tests and procedures that are both adult and pediatric focused:

ASH RECOMMENDATIONS:

1. Don't transfuse more than the minimum number of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable, non-cardiac inpatients).
2. Don't test for thrombophilia in adult patients with venous thromboembolism (VTE) occurring in the setting of major transient risk factors (surgery, trauma or prolonged immobility).
3. Don't use inferior vena cava (IVC) filters routinely in patients with acute VTE.
4. Don't administer plasma or prothrombin complex concentrates for non-emergent reversal of vitamin K antagonists (i.e. outside of the setting of major bleeding, intracranial hemorrhage or anticipated emergent surgery)
5. Limit surveillance computed tomography (CT) scans in asymptomatic patients following curative-intent treatment for aggressive lymphoma.
6. Don't treat with an anticoagulant for more than three months in a patient with a first venous thromboembolism (VTE) occurring in the setting of a major transient risk factor.
7. Don't routinely transfuse patients with sickle cell disease (SCD) for chronic anemia or uncomplicated pain crisis without an appropriate clinical indication.
8. Don't perform baseline or routine surveillance computed tomography (CT) scans in patients with asymptomatic, early-stage chronic lymphocytic leukemia (CLL)
9. Don't test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT
10. Don't treat patients with immune thrombocytopenic (ITP) in the absence of bleeding or a very low platelet count.⁽¹⁾

Recommendations from ASH and American Society of Pediatric Hematology and Oncology:

1. avoid routine preoperative hemostatic testing in an otherwise healthy child with no previous personal or family history of bleeding,
2. avoid platelet transfusion in asymptomatic children with a platelet count >10 × 10 3 /μL unless an invasive procedure is planned,
3. avoid thrombophilia testing in children with venous access-associated thrombosis and no positive family history,
4. avoid packed red blood cells transfusion for asymptomatic children with iron deficiency anemia and no active bleeding, and
5. avoid routine administration of granulocyte colony-stimulating factor for prophylaxis of children with asymptomatic autoimmune neutropenia and no history of recurrent or severe infections.⁽²⁾

ASH RECOMMENDATIONS:

1. Don't image for PE without a moderate to high pre-test probability of PE
2. Don't routinely order thrombophilia testing on patients for infertility testing.

Enforcing these recommendations could eliminate patients receiving results that may do more harm than good.

Present #6: Understanding the impact of anticoagulation on coagulation testing. This translates to providing coagulation laboratories with all anticoagulation patient information. Many laboratories spent an inordinate amount of time testing samples that should not be tested due to the presence of anticoagulation. Results do not reflect the patient's coagulation profile, only the action of the anticoagulant. Upon ordering coagulation tests, information should be required regarding Vitamin K antagonists, Heparins, DOACS and antiplatelet drugs as well as therapies (replacement therapy, Extended half-life therapies). This would be a most advantageous gift!

Present #7: Updated and current guidelines that are accessible and understandable. Having information that can help to harmonize coagulation laboratories is imperative. Being able to ensure that laboratories are performing testing to the best of their ability and having recommendations from global experts can help to drive testing that can be compared between laboratories and ensure quality.

Present #8: Access to continuing education. The field of coagulation is in a constant state of movement. It is near impossible to stay on top of all new developments and how they are relevant to the coagulation laboratory. It is hard to travel to conferences, however with the implementation of webinars, access to CE is possible. Companies have an obligation to their customers to provide them with updates, real life situations that can enhance coagulation knowledge. Lectures need to address everyday coagulation laboratory-based testing issues and not only a specific disorder. This doesn't seem to be the focus of many educational webinars. It is greatly needed for the coagulation laboratory.

Present #9: A better understanding of pre-analytical errors. Most of the errors in the coagulation laboratory are due to errors prior to running the sample. Having either underfilled or overfilled tubes will affect results. Hemolized samples and clotted samples also contribute to issues with testing. Coagulation samples are unstable with most testing only having a 4 hour window for processing or freezing. Understanding how all of these variables impact results is important not only in the laboratory but to those who order tests. Just because you can perform the test, doesn't mean you should!

Present #10: To all the laboratories I wish you a good holiday season, and to remember why you do this, despite all the issues in the laboratory. We are still providing information on someone’s mother, father, sister, brother or child. If I had one present to give I would hope to ignite that one spark in the laboratory. You don't even need a Santa to do that, that is on you!

REFERENCES:

1. Talal Hilalcor and Javier Munoz, Choosing Wisely® in Hematology: Have We Made a Difference?, Curr Hematol Malig Rep. 2020; 15(4): 241–247.
2. Sarah H. O'Brien, Sherif M. Badawy, Seth J. Rotz, Mona D. Shah, Julie Makarski, Rachel S. Bercovitz, Mary-Jane S. Hogan, Lori Luchtman-Jones, Julie A. Panepinto, Ginna M. Priola, Char M. Witmer, Julie A. Wolfson, Marianne Yee, Lisa K. Hicks, The ASH-ASPHO Choosing Wisely Campaign: 5 hematologic tests and treatments to question, Blood Adv (2022) 6 (2): 679–685.