Correspondence
Quality Control of Bone Marrow Aspirates: Additional Steps Toward a Safer and More Efficient Procedure We read with great interest the article by Odejide et al.1 Bone marrow aspiration and biopsy play a central role in the diagnosis and follow-up of many hematological and nonhematological disorders.2,3 Obtaining adequate specimens for pathology analysis is crucial, because nondiagnostic samples often require repetition of the procedure, leading to patient discomfort, familial distress, and increased costs. The causes of bone marrow aspirate failure are diverse and occasionally complex or multifactorial. They may include factors related to the disease (eg, solid tumor infiltration, aplastic anemia, bone marrow fibrosis, or hypocellularity), the patient (eg, radiation therapy, anatomic variation, obesity, agitation, or anxiety), or the operator (eg, anxiety, improper needle location, or experience).4 In addition, it is important to keep in mind that the pathology team can also misclassify an adequate sample as nondiagnostic.4 We would like to contribute to the discussion by reporting the results of our quality-control process of morphologic assessment of bone marrow aspirates during a 6-month period between April 2013 and September 2013. At our institution, we have a team of 26 hematologists who are responsible for bone marrow aspirates and biopsies collected from children and adults in 5 outpatient units and 11 general hospitals in the S~ao Paulo and Recife metropolitan areas of Brazil. Hematologists who performed the procedure also prepared the blood smears; they were assisted by a nurse technician in most cases. As a standard technique, we use 20-mL syringes for aspiration and obtain approximately 0.5 mL of bone marrow aspirate for the preparation of the smears for cytomorphological assessment. We also encourage operators to take advantage of a rapid panoptic stain in cases in which the macroscopic aspect of the smears is put into question. In accordance with our process, if the operator obtains an improper smear (eg, one that is devoid of bone marrow elements), and it is identified by the rapid panoptic stain, it is possible to perform a new procedure before the patient is dismissed. In addition, it is possible to discuss the addition of a bone marrow biopsy with the attending physician who had initially ordered only a bone marrow aspirate. Bone marrow smears were classified according the dilution in peripheral blood as adequate (good number Cancer
May 1, 2014
of bone spicules with little dilution), suboptimal (moderate dilution), and nondiagnostic. The number of procedures per operator varied widely, with a median of 22 procedures (range, 3-110 procedures) performed over the period of the study. The majority of those aspirations included several other tests, such as immunophenotyping, karyotyping, fluorescence in situ hybridization analysis, molecular biology tests, and bone marrow trephine biopsy. The preferred site for the aspirate procedure was the posterior iliac crest at the lateral decubitus; however, puncture at the sternum, although discouraged at our institution, was performed in a few challenging cases. We performed a total of 1126 bone marrow aspirations for morphologic analysis over the 6-month period of the study. Patients had a median age of 48 years (range, birth to 96 years); 555 of the patients (49.2%) were female. We determined a rate of 16.1% suboptimal samples, and 1.3% nondiagnostic samples (samples were too diluted and/or devoid of bone marrow elements). In such circumstances, a new specimen was collected for analysis. In an effort to sustain low rates of suboptimal and nondiagnostic samples, we perform a monthly qualitycontrol evaluation for which each team member completes a form with data regarding the tests collected and the specific conditions of the procedures that were performed. Data from those forms are audited by the leader of the hematology team and a monthly report is compiled detailing individual and team rates of suboptimal and nondiagnostic samples. For professionals with higher rates on those indicators, we offer an opportunity for recycling and one-on-one retraining. These monthly reports are sent to both the hematology and pathology teams, and we hold a regular forum for literature review and technical discussions. In conclusion, our results are similar to those reported by Odejide et al,1 with a trend toward a lower rate of nondiagnostic samples in our series. We believe that the introduction of regular quality audits and reports and a permanent forum for discussion can greatly benefit patients by reducing specimen recollection rates. CONFLICT OF INTEREST DISCLOSURES The authors made no disclosures. Gustavo Loureiro, Edgar G. Rizzatti, Alex F. Sandes, Maria de Lourdes Chauffaille,
MD, MD, MD, MD,
PhD, PhD, PhD, PhD,
Hematology Hematology Hematology Hematology
Fleury Medicine and Health Sao Paulo, Brazil
1441
Correspondence
REFERENCES 1. Odejide OO, Cronin AM, DeAngelo DJ, et al. Improving the quality of bone marrow assessment: impact of operator techniques and use of a specimen preparation checklist. Cancer. 2013;119:3472-3478. 2. Bain BJ. Bone marrow aspiration. J Clin Pathol. 2001;54:657-663. 3. Bain BJ. Bone marrow trephine biopsy. J Clin Pathol. 2001;54:737-742. 4. Bain BJ, Bailey K. Pitfalls in obtaining and interpreting bone marrow aspirates: to err is human. J Clin Pathol. 2011;64:373-379.
hematologic cancers, and we commend Loureiro et al on their effort. CONFLICT OF INTEREST DISCLOSURES The authors made no disclosures. Oreofe O. Odejide, MD Division of Population Sciences Department of Medical Oncology Dana-Farber Cancer Institute Boston, Massachusetts
DOI: 10.1002/cncr.28602, Published online January 30, 2014 in Wiley Online Library (wileyonlinelibrary.com)
Joseph O. Jacobson, MD, MSc Division of Quality and Safety Department of Medical Oncology Dana-Farber Cancer Institute Boston, Massachusetts
Reply to Quality Control of Bone Marrow Aspirates: Additional Steps Toward a Safer and More Efficient Procedure Loureiro et al reemphasize the crucial role of bone marrow assessment in the diagnosis and follow-up of most hematologic malignancies. We agree that the causes of suboptimal bone marrow aspirates and biopsies are diverse and that there are many potential approaches to improve quality. We chose a specimen preparation checklist in our study1 for several reasons. First, many studies have documented the success of checklists in quality improvement.2-4 Second, checklists are relatively easy to implement. Third, checklists can be standardized for adoption by other hematology centers. The approach of Loureiro et al of sharing bone marrow procedure outcomes with hematologists and offering retraining for individuals with high rates of nondiagnostic aspirates is also admirable and has proven beneficial in other settings.5 Several complementary approaches may be needed to achieve the common goal of high-quality care for patients with
1442
Gregory A. Abel, MD, MPH Division of Population Sciences; Center for Leukemia Department of Medical Oncology Dana-Farber Cancer Institute Boston, Massachusetts
REFERENCES 1. Odejide OO, Cronin AM, DeAngelo DJ, et al. Improving the quality of bone marrow assessment: impact of operator techniques and use of a specimen preparation checklist. Cancer. 2013;119:34723478. 2. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732. 3. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491-499. 4. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA; Safe Surgery Saves Lives Investigators and Study Group. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg. 2010;251:976-980. 5. O’Connor GT, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. JAMA. 1996;275:841-846. DOI: 10.1002/cncr.28603, Published online January 30, 2014 in Wiley Online Library (wileyonlinelibrary.com)
Cancer
May 1, 2014
Quality Control of Bone Marrow Aspirates: Additional Steps Toward a Safer and More Efficient Procedure We read with great interest the article by Odejide et al.1 Bone marrow aspiration and biopsy play a central role in the diagnosis and follow-up of many hematological and nonhematological disorders.2,3 Obtaining adequate specimens for pathology analysis is crucial, because nondiagnostic samples often require repetition of the procedure, leading to patient discomfort, familial distress, and increased costs. The causes of bone marrow aspirate failure are diverse and occasionally complex or multifactorial. They may include factors related to the disease (eg, solid tumor infiltration, aplastic anemia, bone marrow fibrosis, or hypocellularity), the patient (eg, radiation therapy, anatomic variation, obesity, agitation, or anxiety), or the operator (eg, anxiety, improper needle location, or experience).4 In addition, it is important to keep in mind that the pathology team can also misclassify an adequate sample as nondiagnostic.4 We would like to contribute to the discussion by reporting the results of our quality-control process of morphologic assessment of bone marrow aspirates during a 6-month period between April 2013 and September 2013. At our institution, we have a team of 26 hematologists who are responsible for bone marrow aspirates and biopsies collected from children and adults in 5 outpatient units and 11 general hospitals in the S~ao Paulo and Recife metropolitan areas of Brazil. Hematologists who performed the procedure also prepared the blood smears; they were assisted by a nurse technician in most cases. As a standard technique, we use 20-mL syringes for aspiration and obtain approximately 0.5 mL of bone marrow aspirate for the preparation of the smears for cytomorphological assessment. We also encourage operators to take advantage of a rapid panoptic stain in cases in which the macroscopic aspect of the smears is put into question. In accordance with our process, if the operator obtains an improper smear (eg, one that is devoid of bone marrow elements), and it is identified by the rapid panoptic stain, it is possible to perform a new procedure before the patient is dismissed. In addition, it is possible to discuss the addition of a bone marrow biopsy with the attending physician who had initially ordered only a bone marrow aspirate. Bone marrow smears were classified according the dilution in peripheral blood as adequate (good number Cancer
May 1, 2014
of bone spicules with little dilution), suboptimal (moderate dilution), and nondiagnostic. The number of procedures per operator varied widely, with a median of 22 procedures (range, 3-110 procedures) performed over the period of the study. The majority of those aspirations included several other tests, such as immunophenotyping, karyotyping, fluorescence in situ hybridization analysis, molecular biology tests, and bone marrow trephine biopsy. The preferred site for the aspirate procedure was the posterior iliac crest at the lateral decubitus; however, puncture at the sternum, although discouraged at our institution, was performed in a few challenging cases. We performed a total of 1126 bone marrow aspirations for morphologic analysis over the 6-month period of the study. Patients had a median age of 48 years (range, birth to 96 years); 555 of the patients (49.2%) were female. We determined a rate of 16.1% suboptimal samples, and 1.3% nondiagnostic samples (samples were too diluted and/or devoid of bone marrow elements). In such circumstances, a new specimen was collected for analysis. In an effort to sustain low rates of suboptimal and nondiagnostic samples, we perform a monthly qualitycontrol evaluation for which each team member completes a form with data regarding the tests collected and the specific conditions of the procedures that were performed. Data from those forms are audited by the leader of the hematology team and a monthly report is compiled detailing individual and team rates of suboptimal and nondiagnostic samples. For professionals with higher rates on those indicators, we offer an opportunity for recycling and one-on-one retraining. These monthly reports are sent to both the hematology and pathology teams, and we hold a regular forum for literature review and technical discussions. In conclusion, our results are similar to those reported by Odejide et al,1 with a trend toward a lower rate of nondiagnostic samples in our series. We believe that the introduction of regular quality audits and reports and a permanent forum for discussion can greatly benefit patients by reducing specimen recollection rates. CONFLICT OF INTEREST DISCLOSURES The authors made no disclosures. Gustavo Loureiro, Edgar G. Rizzatti, Alex F. Sandes, Maria de Lourdes Chauffaille,
MD, MD, MD, MD,
PhD, PhD, PhD, PhD,
Hematology Hematology Hematology Hematology
Fleury Medicine and Health Sao Paulo, Brazil
1441
Correspondence
REFERENCES 1. Odejide OO, Cronin AM, DeAngelo DJ, et al. Improving the quality of bone marrow assessment: impact of operator techniques and use of a specimen preparation checklist. Cancer. 2013;119:3472-3478. 2. Bain BJ. Bone marrow aspiration. J Clin Pathol. 2001;54:657-663. 3. Bain BJ. Bone marrow trephine biopsy. J Clin Pathol. 2001;54:737-742. 4. Bain BJ, Bailey K. Pitfalls in obtaining and interpreting bone marrow aspirates: to err is human. J Clin Pathol. 2011;64:373-379.
hematologic cancers, and we commend Loureiro et al on their effort. CONFLICT OF INTEREST DISCLOSURES The authors made no disclosures. Oreofe O. Odejide, MD Division of Population Sciences Department of Medical Oncology Dana-Farber Cancer Institute Boston, Massachusetts
DOI: 10.1002/cncr.28602, Published online January 30, 2014 in Wiley Online Library (wileyonlinelibrary.com)
Joseph O. Jacobson, MD, MSc Division of Quality and Safety Department of Medical Oncology Dana-Farber Cancer Institute Boston, Massachusetts
Reply to Quality Control of Bone Marrow Aspirates: Additional Steps Toward a Safer and More Efficient Procedure Loureiro et al reemphasize the crucial role of bone marrow assessment in the diagnosis and follow-up of most hematologic malignancies. We agree that the causes of suboptimal bone marrow aspirates and biopsies are diverse and that there are many potential approaches to improve quality. We chose a specimen preparation checklist in our study1 for several reasons. First, many studies have documented the success of checklists in quality improvement.2-4 Second, checklists are relatively easy to implement. Third, checklists can be standardized for adoption by other hematology centers. The approach of Loureiro et al of sharing bone marrow procedure outcomes with hematologists and offering retraining for individuals with high rates of nondiagnostic aspirates is also admirable and has proven beneficial in other settings.5 Several complementary approaches may be needed to achieve the common goal of high-quality care for patients with
1442
Gregory A. Abel, MD, MPH Division of Population Sciences; Center for Leukemia Department of Medical Oncology Dana-Farber Cancer Institute Boston, Massachusetts
REFERENCES 1. Odejide OO, Cronin AM, DeAngelo DJ, et al. Improving the quality of bone marrow assessment: impact of operator techniques and use of a specimen preparation checklist. Cancer. 2013;119:34723478. 2. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732. 3. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491-499. 4. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA; Safe Surgery Saves Lives Investigators and Study Group. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg. 2010;251:976-980. 5. O’Connor GT, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. JAMA. 1996;275:841-846. DOI: 10.1002/cncr.28603, Published online January 30, 2014 in Wiley Online Library (wileyonlinelibrary.com)
Cancer
May 1, 2014
