Haematology

The Department provides a comprehensive Haematology service for the University Hospitals of North Midlands, surrounding GPs and peripheral hospitals as part of the North Midlands and Cheshire Pathology Service (NMCPS).

UKAS accredited Medical Laboratory No 8802.

Our accreditation is limited to those activities described on our UKAS schedule of accreditation

The Haematology Department forms part of the Blood Sciences Department at the University Hospitals of North Midlands. The Department is split over two sites: at the Royal Stoke University Hospital (RSUH) and County Hospital, Stafford.

At RSUH, the Pathology department can be found on the 2nd floor (via Lift A) of the Main building.

The County Hospital Blood Sciences department is located on the 1st floor of the Hospital (follow the signs to Specimen Reception).

The RSUH laboratory is open 24 hours a day, seven days a week, including Bank Holidays. This laboratory provides a wide repertoire of routine and specialist haematology tests and operates 24 hours a day. The vast majority of GP samples from Mid and North Staffordshire are analysed at this site. Outside core hours, services are limited to urgent work only.

The County laboratory is open to receive samples between 06:30 and 23:15, seven days per week, including Bank Holidays. It provides a limited repertoire of essential tests for ward and outpatient activity on the County site. Samples not received in the laboratory by 23:15 are transported to the RSUH Laboratory for analysis, or can be processed using the on-site point of care facilities. All queries regarding County patients outside of the laboratory opening hours should be directed to the RSUH laboratory.

For Haematology Department contact details please click here

The Clinical Haematology team are based at RSUH but provide clinical advice for both sites.

The Haematology Department also encompasses the following sub-departments:

Blood Transfusion

Anticoagulation Management

Specialist Practitioners of Transfusion

Phlebotomy

FBC REFERENCE RANGES

These ranges are age and sex related. Please note that uncertainty of measurement data (UOM) is available on request.

Haemoglobin reference range - premature neonates (g/L)
Gestational age - weeks	Low	High
24-25	179	209
26-27	165	215
28-29	175	211
30-31	169	213
32-33	165	205
34-45	175	217
36-37	177	209

Haemoglobin reference range - Male (g/L)
Age	Low	High
0-7 days	145	220
7-14 days	140	220
14 days to 1 month	125	200
1 -6 months	110	180
6 months - 2 years	100	135
2 - 6 years	105	135
6 - 12 years	110	140
12 - 18 years	115	155
18-65 years	130	160
> 65 years	130	180

Haemoglobin reference range - Female (g/L)
Age	Low	High
0-7 days	145	220
7-14 days	149	220
14 days to 1 month	125	200
1 -6 months	110	180
6 months - 2 years	100	135
2 - 6 years	105	135
6 - 12 years	110	140
12 - 18 years	115	155
18-50 years	120	160
50 - 65 years	115	165
>65 years	115	163

Haematocrit reference range – Male (L/L)
Age	Low	High
0 - 7 days	0.46	0.60
7 - 14 days	0.42	0.64
14 days - 1 month	0.39	0.63
1 - 2 months	0.35	0.55
2 months - 2 years	0.30	0.42
2 - 6 years	0.30	0.42
6 - 12 years	0.33	0.42
12 - 18 years	0.35	0.49
>18 years	0.37	0.51

Haematocrit reference range – Female (L/L)
Age	Low	High
0-7 days	0.46	0.60
7-14 days	0.42	0.64
14 days to 1 month	0.39	0.63
1 - 2 months	0.35	0.55
2 months - 2 years	0.30	0.42
2 - 6 years	0.30	0.42
6 - 12 years	0.33	0.42
12 - 18 years	0.35	0.45
18 - 50 years	0.36	0.46
50 - 65 years	0.37	0.48
>65 years	0.37	0.47

Mean Cell Volume reference range (fL)
	Male		Female
Age	Low	High	Low	High
0 - 7 days	95	125	95	125
7 - 14 days	95	120	90	120
14 days - 1 month	86	120	86	120
1 - 2 months	85	120	85	120
2 - 3 months	80	115	80	115
3 months - 2 years	75	105	75	105
2 - 6 years	70	86	70	86
6 - 12 years	73	85	73	85
12 - 18 years	77	95	77	95
>18 years	78	98	78	100

RBC reference range (x10^12/L)
	Male		Female
Age	Low	High	Low	High
0 - 7 days	3.90	5.50	3.90	5.50
7 - 14 days	3.90	5.50	3.90	6.30
14 days - 1 month	3.60	6.20	3.60	6.20
1 - 2 months	3.00	5.40	3.00	5.40
2 - 3 months	2.70	4.90	2.70	4.90
3 months - 2 years	3.10	4.50	3.10	4.50
2 - 6 years	3.70	5.30	3.70	5.30
6 - 12 years	3.90	5.30	3.90	5.30
12 - 18 years	4.00	5.20	4.00	5.20
18 - 65 years	4.50	5.30	4.10	5.10
>65 years	4.30	5.70	3.80	5.50

MCH reference range - Male and Female (pg)
Age	Low	High
0-14 days	31.0	37.0
14 days to 2 months	28.0	40.0
2 - 3 months	26.0	34.0
3 months - 2 years	25.0	35.0
2 - 6 years	23.0	31.0
6 - 12 years	24.0	30.0
12 - 18 years	25.0	33.0
18 years onwards	26.5	31.5

% Hypo RBC reference range
Age	Male	Female
All ages	≤5%	≤5%

Platelets reference range (x10^9/L)
Age	Male	Female
All ages	150-450	150-450

WBC Reference Range - Male and Female (x10^9/L)
WBC Reference Range - Male and Female (x10^9/L)
Age	Low	High
0 - 14 days	10.0	26.0
14 days - 2 months	6.0	21.0
2 - 6 months	6.0	18.0
6 months - 2 years	6.0	17.5
2 - 6 years	5.0	17.0
6 - 12 years	4.5	14.5
12 - 18 years	4.5	13.0
18 years onwards	4.0	11.0

Neutrophil reference range - Male and Female (x10^9/L)
Age	Low	High
0-2 days	2.9	14.5
3-4 days	1.8	7.2
5 days to 28 days	1.8	5.4
1 month - 8 years	1.0	8.5
8 years - 18 years	1.8	8.0
18 years onwards	2.0	7.5

Lymphocyte reference range – Male and Female (x10^9/L)
Age	Low	High
0-14 days	2.0	11.0
14 days to 1 month	2.0	17.0
1 - 6 months	2.5	16.5
6 months - 1 year	4.0	16.5
1 - 2 years	4.0	10.5
2 - 4 years	3.0	9.5
4 - 6 years	2.0	8.0
6 - 8 years	1.5	7.0
8 - 18 years	1.5	6.8
18 - 65 years	1.5	4.5
65 years onwards	1.5	4.0

Monocyte reference range – Male and Female (10^9/L)
Age	Low	High
0-5 days	0	1.9
5 days to 30 days	0	1.7
1 month - 2 years	0.1	0.8
2 - 14 years	0.1	0.8
14 years onwards	0.2	0.8

Eosinophil reference range – Male and Female (x10^9/L)
Age	Low	High
5 days to 1 month	0	0.8
1 month -5 years	0	0.7
5 - 15 years	0	0.7
15 years onwards	0	0.4

Basophil reference range – Male and Female (x10^9/L)
Age	Low	High
all ages	0	0.1

GLOSSARY OF TERMS USED IN BLOOD FILM REPORTS

ABNORMALITY	DEFINITION	DIAGNOSTIC POSSIBILITIES
Acanthocytes	Red cells with irregular blunt projections	Liver cirrhosis Neurological disorders e.g. Huntington’s Disease Hypothyroidism Hereditary Acanthocytosis
Anisocytosis	Variation in size of red cells	Iron deficiency anaemia Haemoglobinopathies Megaloblastic anaemia
Atypical lymphocytes	Large mononuclear cells with dark blue cytoplasm	Glandular Fever (EBV infection) CMV infection Hepatitis Epilepsy - fitting
Bite Cells	Poikilocytes with one or more semicircular portions removed from the cell margin	G6PD deficiency Haemolytic Anaemia
Blast Cells	Very immature blood cells, not normally seen in peripheral blood	Leukaemia Bone marrow infiltration Marrow Dysfunction
Blood too old for cytological examination	Cells show changes associated with storage	Film made over 12 hours after receipt. Specimen kept at high temperatures before the film made.
Burr Cells	Oval or round red blood cells with regular ‘frilly’ projections	Impaired renal function Haemolytic Uraemic Syndrome Disseminated intravascular coagulation
Crenated red blood cells	Cells with regular spiky projections	Usually artefact due to an old blood specimen or kept in warm temperatures Burns
Dimorphic blood film picture	Two different populations of red cells present	Anaemia on treatment Post transfusion Sideroblastic anaemia Concurrent iron deficiency anaemia and megaloblastic anaemia
Elliptocytes	Oval shaped red blood cells. If very long and thin called pencil cells (resemble small pencils)	Severe iron deficiency Hereditary Elliptocytosis
Gametocytes	Sexual stage of the parasite	Seen in malaria infections
Hairy cells / villous lymphocytes	Large lymphocytes with an indefinite hazy cytoplasmic membrane	Hairy Cell Leukaemia Splenic Lymphoma with villous lymphocytes
Helmet Cells	Fragmented red blood cells that have been "scooped out" so they resemble helmets	TTP/DIC Haemolytic Anaemia Carcinomatosis Prosthetic valve replacements
Howell Jolly Bodies	Small round purple bodies in red blood cells	Poor splenic function Post splenectomy
Hypersegmented neutrophils	Neutrophils with 6 or more lobes	Megaloblastic anaemia
Hypochromia	Low MCH Red cells with enlarged area of central pallor	Iron deficiency anaemia Thalassaemia
Left shifted neutrophils	Many band neutrophils or metamyelocytes present	Infection/Sepsis Leukaemia Treatment with GCSF
Macrocytes/ Macrocytosis	High MCV Large red blood cells	Impaired liver function Megaloblastic anaemia Raised reticulocyte count Hypothyroidism Leukaemia Myelodysplasia
Metamyelocytes	Myeloid precursor cells	Infection Marrow dysfunction Marrow regeneration Leukaemia Megaloblastic anaemia
Microcytes/ microcytosis	Low MCV Small red blood cells	Iron deficiency Haemoglobinopathies Some secondary anaemias
Myelocytes	Myeloid precursor cells	Severe Infection Marrow dysfunction Marrow regeneration Leukaemia Treatment with GCSF
Nucleated red blood cells	Immature erythrocytes (red blood cells)	Normal in neonates esp. when premature Haemolysis Severe anaemia Marrow dysfunction Marrow regeneration Leukaemia
Ovalocytes	Large oval red blood cells	Frequently associated with B12 or folate deficiency
Pappenheimer Bodies	Basophilic inclusions seen in red blood cells	Sideroblastic anaemia Megaloblastic anaemia Alcoholism Splenectomy Some hemoglobinopathies
Pincer Cells	Red blood cells with a small circular region on the periphery of the cells missing	Drug therapy e.g. Dapsone Disseminated Intravascular Coagulation
Poikilocytosis	Irregularly shaped red blood cells	Iron deficiency anaemia Megaloblastic anaemia Myelofibrosis Haemoglobinopathies
Polychromasia	Variation in the colour staining of red cells indicating the presence of mildly immature red cells	Raised reticulocytes due to bleeding, haemolysis, or treatment of anaemia
Right shifted neutrophils	>5 lobes in the neutrophil nucleus	Associated with B12 / folate deficiency
Schistocytes	Small fragmented red cells	Microangiopathic haemolytic anaemia Thrombotic thrombocytopaenic Purpura Haemolysis
Right shifted neutrophils	>5 lobes in the neutrophil nucleus	Associated with B12/folate deficiency
Schistocytes	Small fragmented red cells	Microangiopathic haemolytic anaemia Thrombotic thrombocytopaenic Purpura Haemolysis
Schizonts	Stage at which the malarial parasite starts to divide	Seen in malaria infections
Spherocytes	Small dense red blood cells (with no area of central pallor)	Haemolytic anaemia Hereditary Spherocytosis
Stippled red blood cells (basophilic stippling)	Red cells having many small blue dots within them	Haemoglobinopathies Severe Alcoholism Sideroblastic anaemia Lead poisoning (coarse) Polycythaemia Rubra Vera Acute haemolytic anaemia Bone marrow stress
Stomatocytes	Red blood cells having a horizontal area of pallor across them	Liver disease Altered plasma sodium, potassium or cholesterol levels Hereditary Stomatocytosis
Target Cells	Red cells having a central darker-staining area	Severe iron deficiency Haemoglobinopathies Liver disease
Tear drop poikilocytes	Red blood cells shaped like tear-drops	Myelofibrosis Severe iron deficiency anaemia Megaloblastic anaemia
Trophozoites	Parasite stage most commonly seen in blood film.	Seen in malaria infections.

SPECIMEN TRANSPORT

Royal Stoke University Hospital samples should be sent via the air tube system (or via portering staff in the event of system unavailability). GP samples are usually transported to Pathology via the courier driver system (scheduled collections – to discuss contact Specimen Reception on (6)74881) although there is also a specimen drop off point at the reception desk in the Main Building which is open 24 hours a day.

County samples should be sent via the air tube system (or via portering staff in the event of system unavailability). Samples can be dropped off at the Specimen Reception hatch during routine opening hours (weekdays 09:00 until 17:00). If the access door to Specimen Reception is locked then samples should be placed in the fridge provided for the purpose. This is located in the Blood Issue / Point of Care Room situated on the right hand side of the corridor, before Specimen Reception is reached. In this instance the duty BMS must be contacted via bleep 4751. Between 23:15 and 06:30 when the laboratory is not open to accept samples, samples which require urgent attention must be taken to CH Switchboard where appropriate transportation to RSUH will be organised.

OUT OF HOURS SERVICE

RSUH

The laboratory is routinely open from 09.00 to 18.00 on weekdays. Outside these hours an out of hours service, available for contact via the bleep details below, is in operation. All specimens received in Pathology specimen reception will be prioritised and only those influencing immediate patient care will be tested immediately. The contact details for the out of hours staff is as follows:

RSUH Haematology / Blood Transfusion Biomedical Scientists – Bleep (78) 390

The laboratory is open routinely from 09:00 to 17:00 on weekdays, but operates an extended day service, including weekends and Bank Holidays. Samples are accepted from 06:30 until 23:15. Samples from CH which require testing outside of these hours can be taken to Switchboard for transportation to RSUH. There is also a limited point of care service available.

CH Haematology / Blood Transfusion Biomedical Scientist – Bleep (88) 4751

The following requests will be analysed and results reported via iCM (RSUH) / ICE (CH) within a few hours provided that request cards are filled in correctly and the source of the request can be identified:

FBC
White blood cell differential
Reticulocyte count
INR
APTT
D-Dimer
Fibrinogen

The department will endeavour to contact the requesting source by phone in the instances listed below:

The BMS performing the test has agreed to phone.
Results alert the BMS to the possibility that the patient may need immediate attention.
They are urgent and ward reporting is unavailable

However, in the event that we are unsuccessful in making contact, the results will be available electronically via the ward reporting system. Alternatively the BMS can be contacted via the bleep for urgent results which are not available electronically.

Do not bleep the BMS unless the results are very urgent and need to be telephoned.

Urgent requests requiring prior discussion with BMS staff:

Malarial parasites
Sickle cell screen in appropriate patients requiring urgent general anaesthesia

MEDICAL ADVICE

Royal Stoke University Hospital:

Medical advice on Haematological, Blood Transfusion or related issues can be obtained at all times;

By contacting the duty clinician on bleep 723 between 09:00 and 17:30 on weekdays.
Outside these hours, by contacting switchboard (Internal 0, External 01782 715444), and asking for the Medical Haematologist on call.

County Hospital:

Medical advice on Haematological, Blood Transfusion or related issues can be obtained at all times;

In the first instance, by contacting the duty Specialty Doctor on bleep 4500 between 09:00 and 17:00 on weekdays.
If there is no reply, by contacting switchboard (internal 0, external 01785 257731 or 01782 715444) and asking for the duty clinician on bleep 723.
Outside these hours, by contacting switchboard (internal 0, external 01785 257731 or 01782 715444), and asking for the Medical Haematologist on call.

SPECIMEN ACCEPTANCE CRITERIA AND PRE-ANALYTICAL VARIABLES AFFECTING HAEMATOLOGY RESULTS

Overview

All results produced by the laboratory are dependent upon the quality of the specimens received and accompanying information. Samples should be taken into the correct bottles, which should be correctly filled (this particularly applies to coagulation tests performed from a citrate tube).

The laboratory can only safely process adequately labelled specimens and request cards. Incompletely labelled specimens and requests will not be processed.

When raising a request in iCM the patient demographics are automatically populated and the mandatory fields on the form identify the additional information required for the particular test / referral.

SPECIMEN ACCEPTANCE CRITERIA

Minimum data set for requests

1. Patient identifiable data (minimum of three unique identifiers for a patient):

The unequivocal identity of the patient and/or specimens using the full name of the patient, correctly spelt. A code identifier e.g. for GUM patients or unknown A&E patients is acceptable in place of the patient’s name.
NHS number, hospital unit number or equivalent.
Date of birth.

2. Requestor details:

The source of the request and the destination for results.
The identity (and authority) of the referrer. (When using the ordering on behalf of a referrer option in iCM (RSUH), the referrers name must be recorded as part of the order process).
The identity of the person completing the request/ referral and, where applicable, obtaining the sample/s. (With electronic requests and referrals made on iCM the identity of the person logged onto iCM will be recorded as the person completing the request/ referral).
The identity of the consultant in charge of the patient (this must be completed on all paper request cards and the appropriate field completed in iCM where required). Please note, the full surname and initials should be supplied.

Investigation clinical details

The investigation required to be performed.
Sufficient clinical details to demonstrate that the request is relevant and any other information relevant to the investigation requested that is essential for the correct interpretation of the request, including relevant past medical history, in particular, previous cancer and its treatment.
When requesting using iCM the minimum data set also includes any mandatory fields

Any request or referral submitted on a paper request card should be completed in ink and must be legible. Any paper request / referral form should be signed by an individual authorised to request the investigation.

The minimum requirements for a pathology specimen are:

Specimens relating to the request are attached to the request label / card or other supporting documentation.
The specimen type is suitable for the request made.
The specimen container is appropriate for the investigation and is transported as defined in Policy IC20 (11).
The specimen is correctly stored.
The specimen or request label/card must be labelled with the date and time of sample collection.
The specimen is completed with the minimum data set (see above).
The specimen label matches the request label/ card with respect to the minimum data set.

In instances where a specimen label is electronically produced as part of ordering an investigation on iCM the label produced will link the specimen to the bar-coded request label produced and must be applied to the correct specimen container at the earliest opportunity.

The laboratory will not return samples for re-labelling or amendment.

PRE-ANALYTICAL VARIABLES

A number of non-pathological factors may adversely affect the results obtained from blood samples.

Correct sample from correct patient. Labelling of samples must take place immediately, and include positive identification of the patient.

Labelling - Sample & request form must be correctly filled in; the information on both should match. Incorrect or inadequate information may result in the rejection of specimens and delay results.

Prolonged venous stasis or poor phlebotomy technique may affect the sample integrity. This could cause full or partial coagulation of the sample which would affect both FBC and coagulation test results.

Haemolysis may be caused by expelling blood into the sample tube via the needle or over-vigorous mixing. This will render the sample unsuitable for FBC (cellular components will be broken down), and coagulation testing (activation of the clotting system may shorten clotting times).

Correct dilution - Coagulation samples tubes must be filled to the frosted line on the tube. Under or over dilution will give inaccurate results.

Inappropriate sample – The correct anticoagulant must be used: EDTA (purple top) for FBCs and trisodium citrate (blue top) for coagulation testing.

Transport and Storage - Full blood counts and coagulation samples should be tested as soon as possible after collection. Delays and incorrect storage (too hot or cold) will adversely affect results. Degenerative changes are retarded but not abolished at 4˚C. Coagulation samples at room temperature should ideally be tested within 3 - 6 hours; INRs are stable at 4˚C for up to 24 hours and APTTs for 9 -12 hours. ESRs should be processed within 8-12 hours of collection and should not be requested as an add-on request after that time.
For information regarding venepuncture please click here, then select 'Nursing Workbooks' and read 'The Venepuncture Workbook'

Other sampling problems which may affect results:

Vigorous exercise

Certain drug treatments

Direct sunlight on the samples

Patient having blood taken from an arm with a drip in situ

Lipaemia

Leaking or broken samples will not be processed.