NATOMY OF A GOOD FINGERSTICK BASE - Doctor …Cleanse the finger. WAIT for the prompt before incising the finger. 4. INCISE THE FINGER Place Tenderlett® Plus firmly against ...

Fin•ger•stick \fin-gerstik\ a :the art of properly stickingone’s finger to retrieve blood.

An improper incision willcause blood to run down

the side of the finger.

The key to obtaining a good ProTime result is collecting a good fingerstick sample.

• Choose middle or ring finger.

• Warm and massage hand to stimulateblood flow, while keeping the handbelow heart level.

• Have patient give you a ‘High-Five’ or‘Low-Five’ (when instrument prompts to‘incise finger’).

• Place Tenderlett Plus at 90º angle to finger.

• Always incise side of finger closest tothe pinky, at a 10:00 or a 2:00position.

• ‘High-Five’~ pivot Tenderlett PlusTIP towards pinky.

• ‘Low-Five’~ pivot Tenderlett PlusBASE towards pinky.

• Firmly press Tenderlett Plus to finger and trigger with thumb.

• Wipe away the first trace of blood.

• Position the hand perpendicular to theground, like a handshake, to collectblood.

• Squeeze and release the finger pad toobtain ONE LARGE, HANGING DROP OF BLOOD.

Place Tenderlett Plusat 90º angle tofinger. Alwaysincise side of fingerclosest to the pinky.

ANATOMY OF A GOOD FINGERSTICK

TIP

BASE

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Test Procedure: follow the prompts on the screen.

Controls OKPID = 123456789012OID = 123456INR = 2.0PT = 26.1$ MAIN MENU# TURN OFF

MWM:107 4/06

ProTime and Tenderlett are registered trademarks of ITC.

1. TURN ON ProTime®

Press the # button.Watch the screen and follow theprompts.

2. INSERT TEST CUVETTEThe barcode should be face down.ProTime warms the cuvette.WAIT for the prompt before incisingthe finger.

3. PREPARE THE FINGERWarm the hands to stimulate blood flow.Cleanse the finger.WAIT for the prompt before incisingthe finger.

4. INCISE THE FINGERPlace Tenderlett® Plus firmly againstside of finger.Place thumb over the red trigger as shown.Press the red trigger.

5. FILL CUP TO LINEWipe away the first drop of blood.Form one LARGE DROP of blood.Touch drop to cup.FILL to the line indicated by the arrow.

6. SNAP Tenderlett PlusONTO ProTime

Hold the Tenderlett Plus at an angle.Place cup end into slot.Press down to click in place.

7. PRESS THE # BUTTONPress the # button.FOLLOW the prompts on thescreen.

8. REMOVE Tenderlett PlusWhen PROMPTED remove theTenderlett Plus.ProTime allows you six seconds toremove Tenderlett Plus.

9. READ RESULTSThe results remain displayed for fiveminutes.

ITC Technical Supportphone: 1-800-631-5945

fax: 1-732-548-9824email: [email protected]

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1. INCISE FINGER2. APPLY BLOOD3. PRESS #

TIME LEFT1.01

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ProTime® Microcoagulation System

Clinical and Laboratory Standards Institute (CLSI) Formatted Procedure

Director’s Signature: _________________________________________________________

Date for Reviews: ____________________________________________________________

Prepared by Date: ___________________________________________________________

Adopted Date: ______________________________________________________________

Supersedes Procedure Number:________________________________________________

Review Date: _______________________________________________________________

Signature: __________________________________________________________________

Distributed To: ______________________________________________________________

Number of Copies: ___________________________________________________________

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TABLE OF CONTENTS

I. PURPOSE ......................................................................................................................... 3II. PRINCIPLE ........................................................................................................................ 3III. SPECIMEN ........................................................................................................................ 3

A. Patient Preparation .......................................................................................................... 3B. Specimen Type ............................................................................................................... 4C. Sample Collection Procedure/Handling Conditions ......................................................... 4D. Preparation for Finger Incision ........................................................................................ 4E. Sample Collection: Fingerstick Procedure ....................................................................... 4F. Sample Collection: Venous Procedure ............................................................................ 5G. Cuvette Notes/Interferences ............................................................................................ 5H. Operational Precautions .................................................................................................. 5

IV. EQUIPMENT/MATERIALS/REAGENTS ............................................................................ 5A. Materials .......................................................................................................................... 5B. Additional Materials Required .......................................................................................... 6C. Reagent Preparation ....................................................................................................... 6D. Storage Requirements ..................................................................................................... 6

V. QUALITY CONTROL (QC) ................................................................................................ 6A. Use of Optional External DirectCheck Whole Blood Controls (DCPRO)Handling and

Storage ............................................................................................................................ 6B. Out-of-Range Quality Control Procedure ......................................................................... 8

VI. Patient ID (PID) and/or Operator ID (OID) Entry ................................................................ 8VII. STEP-BY-STEP TEST PROCEDURE ............................................................................... 9

A. Turn on the ProTime Instrument ...................................................................................... 9B. Insert a Cuvette ............................................................................................................... 9C. Prepare for Finger Incision and Collect the Blood Sample .............................................. 9D. Start the Test ................................................................................................................... 9E. Remove the Tenderlett Plus ............................................................................................ 9F. Read the Result ............................................................................................................... 9

VIII. CALCULATIONS .............................................................................................................. 10IX. READING and REPORTING RESULTS .......................................................................... 10

A. Reportable Ranges ....................................................................................................... 10B. Procedures for Abnormal Results .................................................................................. 10

X. LIMITATIONS .................................................................................................................. 11XI. MAINTENANCE ............................................................................................................... 12

A. Cleaning ........................................................................................................................ 12B. Battery Care .................................................................................................................. 12C. Rechargeable Battery Facts .......................................................................................... 12D. Battery Replacement ..................................................................................................... 12E. Service .......................................................................................................................... 13F. Instrument Downtime ..................................................................................................... 13

XII. PROFICIENCY TESTING ................................................................................................ 13XIII. EMPLOYEE CERTIFICATION ......................................................................................... 13

Refer to the ProTime® Operator’s Manual and cuvette package insert for completeinstructions for test and instrument performance.

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I. PURPOSE

The ProTime Microcoagulation System is a portable, AC or battery-operated instrument with adisposable cuvette for quantitative determination of prothrombin time (PT) from fingerstickwhole blood or anticoagulant-free venous whole blood. The product is intended for in vitrodiagnostic use in the management of patients treated with oral anticoagulants.

II. PRINCIPLE

The ProTime Microcoagulation System measures the PT using fibrin clot formation anddetection. The ProTime cuvette is a self-contained, micro volume reaction cell constructed ofprecision molded plastic.

There are two user options within the ProTime Microcoagulation System: the standard ProTimecuvette and the ProTime3 cuvette. These cuvettes differ from each other in the amount ofblood collected.

The standard ProTime cuvette has five micro-channels which contain the dried reagentsrequired to perform triplicate testing of the prothrombin time assay and two levels of controls.The ProTime3 cuvette has three functional micro-channels. Two micro-channels perform thecontrols, and one micro-channel performs the prothrombin time assay. The standard ProTimeuses the Tenderlett® Plus device for performing the fingerstick and it is designed to hold 65 lof blood (approximately 3 drops) needed to fill all five micro-channels. The ProTime3 uses theTenderlett Plus LV (lower volume) device for performing the fingerstick and it collects the 27 lof blood (approximately 1 large drop) needed to fill the three micro-channels of the ProTime3cuvette.

The instrument draws the precise volume of blood into the micro-channels of either cuvette,which contain thromboplastin and other reagents. An array of LEDs detects the motion ofsample/reagent mixtures as they move through a precision restriction in each channel. Theblood is pumped back and forth until a clot forms, obstructing the channels and slowing theflow of blood. The instrument detects the clot when the blood movement decreases below apredetermined rate.

III. SPECIMEN

A. Patient Preparation

Either the Tenderlett Plus (ProTime) or Tenderlett Plus LV (ProTime3) is supplied for fingerincision and blood collection. The Tenderlett Plus will collect approximately 65 l of blood,while the Tenderlett Plus LV will collect approximately 27 l of blood. Samples should beanalyzed immediately after collection. No additional sample preparation is required. Refer tothe Test Procedure in the package insert for full instructions on hand preparation, fingerincision and blood collection. Refer also to CLSI H4, “Procedures for the Collection ofDiagnostic Blood Specimens by Skin Puncture.”

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For venous samples, collect venous whole blood (approximately 100 l) into an anticoagulant-free plastic syringe. Refer to CLSI H3, “Procedure for the Collection of Diagnostic BloodSpecimens by Venipuncture.”

B. Specimen Type

Fingerstick whole blood is the recommended specimen. Anticoagulant-free venous wholeblood may be used if the sample is collected into a plastic syringe. (Glass activates the clottingprocess and could therefore interfere with the results.)

NOTE: Whole blood collected with citrate, heparin, oxalate or EDTA anticoagulants are NOTsuitable for use with the ProTime Microcoagulation System. Serum or plasma samples are notappropriate samples.

C. Sample Collection Procedure/Handling Conditions

Patient specimens and used cuvettes are potentially infectious. Use universal precautions inthe handling of cuvettes and blood collection materials in accordance with local standards ofbiohazard control.

D. Preparation for Finger Incision

Warming the hands increases blood flow and makes it easier to collect an adequate volume ofblood. Follow these steps to help ensure a good sample:

• Wash hands in warm water.• Rub hands together to stimulate blood flow.• Cleanse middle or ring finger with an alcohol pad and dry with sterile gauze.• Apply firm pressure to the palm and finger. Massage the hand to push blood into the

fingertips.

E. Sample Collection: Fingerstick Procedure

Wait for screen that instructs to “Incise Finger” to appear before incising finger.

CAUTION: Blood collection must be finished within 2 minutes and 10 seconds toprevent early clotting of the sample. The ProTime device will keep time.

• Place the Tenderlett Plus device firmly against the side of the finger. Place thumb ontop of the device and press the red trigger using the other thumb while holding theTenderlett in place.

• Wipe away the first trace of blood. The use of gauze is recommended. Cottonswabs should not be used as loose fiber strands can potentially activate clotting.

• Gently massage from the base of the finger to force blood to the tip. Form a largedrop of blood.

• Touch the large drop of blood to the collection cup. Keep adding blood until theblood level passes the line on the collection cup.

• Ensure the blood extends all the way to the bottom of the cup. Add another drop ifyou are not sure you have enough.

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F. Sample Collection: Venous Procedure

Wait for the screen that instructs to “Incise Finger” to appear before obtaining venous sample.

CAUTION: Blood collection must be finished within 2 minutes and 10 seconds toprevent early clotting of the sample. The ProTime device will keep time.

• Follow standard phlebotomy protocol for obtaining venous sample using a syringe.• Obtain a minimum 100 l sample.• Using the syringe, administer blood to the collection cup. Keep adding blood until

the blood level passes the line on the collection cup (fills the Tenderlett LV cup).• Ensure the blood extends all the way to the bottom of the cup. Add another drop if

you are not sure you have enough.

G. Cuvette Notes/Interferences

• Make sure cuvettes have been brought to room temperature prior to testing.• Cuvettes are for single use only. Do not re-use a cuvette once it has been inserted

into the analyzer.• Do not begin sample collection OR add sample to Tenderlett Plus cup before

instrument instructs to “Incise Finger.”• Always wipe away first trace of blood after incising finger.• Do not use samples collected with citrate, heparin, oxalate or EDTA anticoagulants.

H. Operational Precautions

• Use universal precautions when handling blood.• Place the ProTime cuvette into the analyzer within 8 hours of opening the package. If

more than 8 hours elapse, discard the cuvette and use a new cuvette.• Make sure to remove the Tenderlett Plus cup when instrument instructs to do so.

IV. EQUIPMENT/MATERIALS/REAGENTS

Each box of ProTime cuvettes contains 25 individually pouched cuvettes and 25 individuallypouched Tenderlett Plus devices. Cuvette and Tenderlett Plus pouches are stamped with a lotnumber and expiration date.

CAUTION: All used cuvettes and Tenderlett Plus devices should be considered aspotentially infectious, handled using universal precautions and disposed of by followingyour standard waste facility disposal policy.

A. Materials

• ProTime Instrument• AC/DC Power Module (optional)• ProTime Cuvette• Tenderlett Plus collection device

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B. Additional Materials Required

• Alcohol pad• Gauze

C. Reagent Preparation

ProTime cuvettes are ready-to-use. No additional preparation is required. Remove cuvettefrom refrigeration and allow it to come to room temperature prior to testing.

D. Storage Requirements

Store the foil-pouched cuvettes refrigerated (2-8°C, 35-46°F). An unopened cuvette is stablewhen stored at 2-8°C until the date printed on the pouch. Unopened cuvettes may be stored atroom temperature for 60 days. Once the pouch has been opened, the cuvette must be usedwithin 16 hours.

V. QUALITY CONTROL (QC)

The ProTime instrument performs a self-check before every test and has been designed withredundant systems to ensure proper instrument functions. The self-check at start-up checkstemperature, timing functions, battery level, and optical, electrical and mechanical functions.No additional calibration or functional procedures are required.

Each ProTime cuvette has two levels of integral reagent controls that are run with every patientsample. The built-in controls indicate proper sample collection and correct test procedure,ensuring assay reliability and performance. Both control channels contain human coagulationfactors designed to normalize the clotting time of the blood sample. In addition, the level 2control channel has extra reagent which causes an extended clotting time. If the built-incontrols do not perform as expected, the result is invalid and the instrument will display anerror code. The use of external quality control material is not required but available if needed.

The ProTime cuvette includes a barcode that contains the cuvette lot number and expirationdate and the lot specific algorithm for calculating the results in each channel. The barcode alsocontains the lot specific requirements for the integral control channels to meet in order for theinstrument to report a patient result.

(Add your institution’s policy here, if applicable.)

A. Use of Optional External DirectCheck Whole Blood Controls (DCPRO)Handlingand Storage

When refrigerated (2–8°C, 35-46°F) the DCPRO vials are stable until the marked expirationdate. The quality control product should never be exposed to temperatures in excess of 37°C,98.6°F. Reconstituted vials should be used immediately. DCPRO may also be stored at roomtemperature for up to 4 weeks. (The marked expiration date must not be exceeded.) A re-dating label is provided and should be marked with 4 weeks dating if room temperature storageis selected.

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Materials ProvidedDCPRO quality controls are designed for use with the ProTime Microcoagulation System.Each kit contains a single level of quality control reagent consisting of 15 dropper vials of0.5 cc dried whole blood control in a glass ampule and 0.7 cc of diluent. There are four re-usable protective sleeves provided for use in crushing the vials.

Materials Required But Not Provided• ProTime instrument• ProTime / ProTime 3 cuvette• Tenderlett Plus/ Tenderlett Plus LV sample collection device

Preparation of Control MaterialRemove the control vials from the refrigerator and allow them to come to room temperatureprior to use.

Q.C. Test ProcedureNOTE: Reconstitution and mixing of the whole blood control material should be accomplishedquickly and without delay in any step. Once the dried control material has been reconstituted,the sample should be used immediately, as clotting will occur.

• Turn on the ProTime instrument and from the “Main Menu” select “Run LQC.”After self-check is completed, the instrument will display, “Insert Cuvette.”

• Insert cuvette into slot in the front of the instrument. The printing should be faceup and the barcode should be face down.

• After warming, the instrument will signal ready by prompting for samplecollection.

• Reconstitute the (room temperature) dropper vial contents as follows:• Remove the label from the vial. Insert vial into protective sleeve. While holding

the vial upright, tap the vial on a table top to settle the glass ampule to the bottomof the vial. Crush the inner glass ampule by either bending the vial over the edgeof a table top or by crushing the vial between two fingers. Immediately repeat thecrushing action two to three additional times to ensure complete breakage of theglass ampule. Quickly invert the dropper vial end to end 10 times.

• While inverting the vial (dropper tip down), use a downward snapping motion tothe wrist to ensure the control material flows to dropper tip. Remove and retainthe vial cap. Squeeze the vial to discard the first drop of the control material intothe vial cap. Immediately dispense as many drops of control material as neededto fill the Tenderlett Plus collection cup until it passes the line or to completely fillthe Tenderlett Plus cup.

• Snap the Tenderlett Plus to the ProTime instrument, you should hear a soft click.• Follow the display to start the test. When prompted, remove the Tenderlett Plus

from ProTime instrument.• Remove the control vial from the protective sleeve. Dispose of the vial and vial

cap appropriately and retain the protective sleeve for reuse.• Record results.

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CAUTION: No human material is used in the control product. However, all blood productsshould be handled with care, and should be discarded in accordance with your institution’spolicy on disposal of medical waste.

B. Out-of-Range Quality Control Procedure

In cases where quality control results are outside of an acceptable range, the cause is likelyattributable to one of the following categories:

• Test technique• Control material• Cuvette• Instrument• If results are outside of the acceptable range, the following items should be

verified immediately:o Control material expiration dateso Proper techniqueo Presence of bubbles in the sample cup or cuvette channels

• If none of the above parameters are suspect, repeat the test using controlmaterials with the identical lot number.

• If this repeat does not fall within the expected range, verify the above parametersagain. Obtain a cuvette from a different lot number and repeat the test using acontrol with the same lot number.

• Obtain control material with a different lot number and repeat the controls again.• If this repeated control does not fall within the expected range, contact your

laboratory consultant or call ITC Technical Support.• Additional test should not be performed until control values obtained are within

range.

The liquid quality control products are helpful when an instrument problem is suspected. It isrecommended that multiple tests be performed with the quality control products, and that thedata be discussed with an ITC Technical Support representative prior to sending theinstrument to ITC for service. Call toll free in the U.S. (800) 631-5945, or (732) 548-5700 ifcalling from outside the U.S or e-mail us at [email protected].

VI. Patient ID (PID) and/or Operator ID (OID) Entry

Go to the “Main Menu” screen and choose the “Set Up’ option. Scroll and select “SETPID/OID” to access this option. The PID can be up to 12 digits in length and the OID up to 6digits in length.

• Selecting PID/OID ON enables both a patient ID and operator ID to be entered.• Selecting PID ON enables only a patient ID to be entered.• Selecting OID ON enables only an operator ID to be entered.• Selecting OFF disables both the patient ID and operator ID.

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VII. STEP-BY-STEP TEST PROCEDURE

A. Turn on the ProTime Instrument

Press the 0 button to start. ProTime does a self-check procedure which may take up to 60seconds. ProTime will prompt you through the test. Watch the screen and follow the prompts.

B. Insert a Cuvette

Wait for the prompt. Insert the cuvette into the slot with the printed side face up and thebarcode down. If either OID or PID is required, ProTime will prompt for this information. Usethe select button to scroll through the digits 0 – 9 under the cursor. Press the “0” button toaccept and advance to the next digit. Continue until entry is complete. Press the “0” button toconfirm entry. While the cuvette is warming, prepare the finger. Wait for the prompt beforeincising the finger and collecting blood.

C. Prepare for Finger Incision and Collect the Blood Sample

• Snap Tenderlett Plus to ProTime instrument• Hold the device at an angle and place the front end of the device into the slot in

the instrument.• Press down to click the Tenderlett Plus in place. You should hear a soft click.

Proper engagement of the Tenderlett Plus to the cuvette is critical to prevent asample error.

D. Start the Test

Press the 0 button to start the test. This signals the ProTime instrument to draw the sampleinto the cuvette. It takes only a few seconds for the ProTime device to draw the blood into thecuvette. Watch the screen for the next prompt.

E. Remove the Tenderlett Plus

Remove the Tenderlett Plus from the ProTime instrument when prompted to do so.

CAUTION: Remove Tenderlett Plus immediately. The ProTime instrument allows you6 seconds. Failure to do so will result in an error message.

F. Read the Result

Results will be displayed on test completion. If the ProTime device is connected to a printer orcomputer and the “AUTO SEND” feature is turned on, the result will automatically betransmitted to a serial printer or computer by using the PROCABLE.

Press the SELECT button to go to the MAIN MENU if you want to review the data in memory,print results, transfer results to a computer or perform set up functions. Press the 0 button totune off the ProTime instrument.

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VIII. CALCULATIONS

The INR and PT seconds are displayed for each result. There are no user defined calculationsrequired.

IX. READING and REPORTING RESULTS

The ProTime device reports results as International Normalized Ratio (INR) and PT seconds.The ProTime system calculates INR directly from whole blood clotting time based on aconversion equation that was established in clinical trials. The result in plasma equivalentseconds is then calculated from the INR result.

Since results reported in PT seconds depend on the sensitivity (ISI) of the reagent employed,the clinician has the option of changing the ISI value in ProTime so that the ProTime resultsreported in PT seconds closely match the results reported by the hospital laboratory. Tochange the ISI used in the calculation, access the “PROGRAM MODE” by selecting “SET UP”in the “MAIN MENU” and enter the ISI of the local laboratory reagent. The INR result isunaffected by changing the ISI setting.

A. Reportable Ranges

In clinical trials, no significant difference was observed between fingerstick and venousspecimens run on the ProTime system. The ProTime instrument measured patients with anINR range of 0.8 to 7.0. If INR>7.0, the numerical result is marked with “*”. An error message isdisplayed if INR>10.0.

The ProTime system measures both normal and therapeutic prothrombin times in fresh wholeblood. Results are displayed in plasma equivalent seconds and INR. Expected values forpatients taking oral anticoagulants depend on the patient’s disease state and the target valuesestablished by the physician.

B. Procedures for Abnormal Results

As with all diagnostic tests, test results should be scrutinized in light of a specific patient’scondition and anticoagulant therapy. Any results exhibiting inconsistency with the patient’sclinical status should be repeated or supplemented with additional test data.

(Identify your procedure for reporting abnormal/unexpected results here.)

PROCEDURAL NOTES:• DO NOT use cuvettes past their expiration date or if they have been stored

improperly.• DO NOT force a cuvette into the instrument. If resistance to insertion is

encountered, gently remove the cuvette and examine the cuvette slot. Removeany obstruction before attempting to insert the cuvette.

• DO NOT use excessive force in depressing any of the soft touch keys.• DO NOT disturb the instrument while a test is in progress.

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• DO NOT expose the ProTime instrument to extremes in temperature (above35°C, 95°F). Such exposure could affect the performance of any type ofelectronic equipment.

• DO NOT attempt to open the ProTime instrument other than for batteryreplacement, as there are no user-serviceable parts.

• DO NOT remove the AC/DC power module from the ProTime instrument bypulling on the cord.

• The ProTime instrument is designed for use only with ProTime cuvettes.• Results from the ProTime device can be affected by poor technique during blood

collection and delivery to the sample cup. The accuracy of the test is largelydependent upon the quality of the sample collection and the transfer of the bloodto the cuvette. Tests may be affected by (but not limited to) any of the followingconditions:

o Delay of longer than 2 minutes from obtaining sample to running testo Foaming of the sample (air bubbles)o Clotted or partially clotted bloodo All biohazard safety guidelines pertaining to the handling of human blood,

such as the CDC guidelines of universal precautions, should be strictlyadhered to when collecting, handling blood specimens and operating theProTime.

o Used ProTime cuvettes and Tenderlett Plus devices should be considered aspotentially infectious. They should be handled according to individualinstitutional policies concerning the disposal of potentially infectious materials.

X. LIMITATIONS

The ProTime instrument uses only fresh capillary or venous whole blood. Plasma or serumcannot be used. Glass tubes or syringes must not be used to collect venous samples. Useonly plastic syringes without anticoagulants to collect venous samples.

• Poor fingerstick blood collection technique may affect results.• Results may be affected in patients receiving supra-therapeutic heparin or who

have an abnormal response to heparin.• Correlation of results reported by ProTime to laboratory results depends on the

precision of the laboratory method and on the ISI value of the laboratory reagentand instrument system.

• As with all diagnostic tests, ProTime test results should be scrutinized in light of aspecific patient’s condition and therapy. Any results exhibiting inconsistency withthe patient’s clinical status should be repeated or supplemented with additionaltest data.

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XI. MAINTENANCE

A. Cleaning

• DO NOT immerse the ProTime instrument or allow fluid to enter the cuvettehousing. Inspect and clean the outside of the cuvette slot as required. Removeresidual dried blood or other foreign matter on the outside of the instrument usinggauze dampened with a 10% dilution of household bleach in water or with gauzedampened with isopropyl alcohol or other disinfectant.

• DO NOT use other solvents or strong cleaning solutions as they may damage theplastic components of the instrument.

B. Battery Care

The ProTime instrument is designed to run either on AC power supplied by the AC/DC powermodule or on the rechargeable battery supplied within the unit.

C. Rechargeable Battery Facts

Batteries discharge naturally over time (approximately 5% per month). Battery capacity (theamount of charge the battery will hold) is lower at low temperatures.

The ProTime instrument uses a rechargeable NiMH (Nickel Metal Hydride) type battery.The maximum capacity of any rechargeable battery will gradually decrease over time.To ensure maximum life of the rechargeable battery, follow the guidelines below.

A new instrument, an instrument that is used infrequently, or an instrument with a newreplacement battery, should be plugged in for at least 8 hours before use to ensure that thebattery is completely charged. The instrument screen will show CHARGING BATTERY whenthe AC/DC power module is connected to the AC power cord and the ProTime instrument. Thescreen will show CHARGE COMPLETE when the battery is fully charged. The AC/DC powermodule may be disconnected after the CHARGE COMPLETE message is seen. The AC/DCpower module that has been supplied by ITC has been selected specifically for use with yourProTime Microcoagulation System. Do not use any other AC/DC power module. When thebattery indicator on the screen shows less than 25% charge remaining, the instrument shouldbe plugged in. To maximize battery life, allow your ProTime instrument to discharge completelybefore re-charging. Avoid charging the ProTime instrument for frequent, short periods of time(such as charging for a few minutes, removing from the AC/DC power module, and thenrecharging again).

D. Battery Replacement

Refer to the instructions provided with the replacement battery. The used battery should bedisposed of in accordance with local regulations for NiMH batteries.

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E. Service

Other than replacement of the rechargeable battery as described above, the ProTimeinstrument is not user serviceable. Should service be required, please contact TechnicalSupport at 1-732-548-5700, 1-800-631-5945, or e-mail us at [email protected]. If youare advised to return the instrument to ITC for service or repair prior to shipping, please cleanthe instrument as described above.

F. Instrument Downtime

During instrument downtime, patient samples will be tested on alternate ProTime instruments.If all instruments are down, patient samples will be tested in the clinical laboratory.

XII. PROFICIENCY TESTING

(Proficiency testing is only required in some states for CLIA-waivedsystems. Delete if this does not apply to your institution.)

Proficiency testing will be performed at least twice per year using linearity kit samples obtainedfrom an outside testing institution. The results will be returned to the outside testing institute bythe specified date. If the results from both the primary and secondary machines are not at least80% acceptable, the unacceptable grade will be reported to your technical consultant ormedical director.

XIII. EMPLOYEE CERTIFICATION

Employee certification is completed upon in-servicing, and should be renewed at theinstitution’s required frequency for all certified operators of the ProTime system.Documentation of certification is maintained in the employee’s personnel folder.

A COMPARATIVE EVALUATION OF THREE POINT-OF-CAREPROTHROMBIN TIME TESTS, PROTIME, PROTIME3 ANDINRATIO, TO A LABORATORY REFERENCE STANDARD

Marsha Patsch, Catherine Cimini, Ph.D.

SUMMARYPurpose: An in-house study was conducted using clinical specimens obtained from the ITC out-patient clinic to compare three point-of-care (POC) Prothrombin Time (PT) systems, ProTime(“ProTime5,” full volume 5-channel test), ProTime3 and INRatio, to the laboratory reference.

Methods: Whole blood samples (fingerstick and venous) were obtained from patients on oralanticoagulant therapy (Coumadin, Warfarin) and tested on the POC systems. Venous sampleswere tested on two instruments to evaluate precision. Venous samples (plasma) also underwenttesting on a laboratory reference system using an MLA Electra 900 (Medical LaboratoryAutomation, Pleasantville, NY) and Dade Innovin reagent (ISI=0.98, Dade Behring, Newark, DE)to assess accuracy.

Results: Accuracy using Venous Samples: All POC tests were highly correlated to the labreference system with r=0.96, 0.93, and 0.96 for ProTime5, ProTime3, and INRatio, respectively.Relative differences between each POC test and the reference system were calculated with respectto INR range, <2.5 and > 2.5. INRatio was statistically different (p<0.05) from the reference systemin both ranges while ProTime5 and ProTime3 were equivalent to the reference system, regardlessof INR range.

Accuracy with Fingerstick Samples, ProTime3 vs. INRatio: Both POC tests were highly correlatedto the reference system with r=0.92 and 0.97 for ProTime3 and INRatio, respectively. Relativedifferences were calculated between each POC test and the reference with respect to INR range,<2.5 and > 2.5. INRatio was statistically different from the reference system for INR values > 2.5(p<0.05). ProTime3 was equivalent to the reference system, regardless of INR range.

Accuracy with Fingerstick Samples, ProTime5 vs. INRatio: Both POC tests were highly correlatedto the lab reference system with r=0.97 and 0.98 for ProTime5 and INRatio, respectively. Relativedifferences were calculated between each POC test and the reference with respect to INR range,<2.5 and > 2.5. INRatio was statistically different from the reference system (p<0.05) for INR values> 2.5. ProTime5 was equivalent to the reference system, regardless of INR range.

Precision: Pooled SD, which provides a measure of reproducibility, was calculated with duplicateresults collected with ProTime3 and INRatio. Pooled SD=0.24 and 0.37 for ProTime3 and INRatio,respectively.

“No Result” Rate: During the performance of this study, no result was periodically obtained due tovarious sampling, internal control or technical test errors. The “no result” rate was lower for bothProTime assays compared to INRatio with rates equal to 5.4%, 4.2%, and 11.2% for ProTime3,ProTime5, and INRatio, respectively.

Conclusion: Results demonstrate all POC systems were highly correlated to a standard laboratoryreference method. INRatio demonstrated a positive bias that was exaggerated in the higher INRrange. The ProTime Microcoagulation System (ProTime5 and ProTime3) demonstrated a smallerbias and accurate INR results across the entire INR range. Results confirm both ProTime assays areappropriate for monitoring the coagulation status of patients on oral anticoagulant therapy. It isimportant that all sites establish their own correlation with the local laboratory to identifyinstitutional variation between POC systems and their unique reference systems.

INTRODUCTION

The ProTime Microcoagulation System (ITC, Edison, NJ) has been used to manage patients onCoumadin therapy in professional and patient self-testing settings since 1995 and 1996,respectively. This system employs a 5-channel assay (ProTime5) which is unique in triplicate PTtesting and on-board controls. A second assay, ProTime3, was added to the system in 2001 tomeet the need for a PT test requiring less blood. This assay is a single PT test with on-boardcontrols. Other test systems have entered the POC PT marketplace, including the INRatio PTMonitoring System (HemoSense, Milpitas, CA). To date, no comparison of these systems has beenpublished.

POC system accuracy is typically validated by comparing INR results between the POC systemand a common laboratory reference. POC precision is evaluated by obtaining repeat testmeasurements. This study compares accuracy and precision of these POC systems.

METHOD

Fresh whole blood samples (n=37), collected from patients on long-term anticoagulant therapy viavenipuncture, were tested simultaneously using a split-sample experimental design. Multiple lots(n=3) of each POC assay were tested in this study. Two lots were used for each POC assay in thevenous phase of the study. Different lots were evaluated in the fingerstick phase for each POCassay. Venous samples were tested on two instruments simultaneously for ProTime3 and INRatio,creating the duplicate testing for precision evaluation of these systems. Venous blood wascollected (3.2% sodium citrate) from patients at the time of POC testing in both the venous andfingerstick phases for comparative laboratory plasma results. Plasma was tested using thelaboratory reference system, MLA Electra 900 (Medical Laboratory Automation, Pleasantville, NY)and Dade Innovin reagent (ISI=0.98, Dade Behring, Newark, DE). The MLA-Innovin system usedin this study has been verified against a national reference laboratory (Midwest Hemostasis,Muncie, IN). The acceptability of this system is substantiated as it has been part of a proficiencytest program (College of American Pathologists or CAP) since 1999 in which it consistentlyperformed within ±1 SD of the proficiency program’s nominal result (internal ITC data).Furthermore, MLA instrumentation is cited in the package insert of all POC systems underinvestigation as the reference instrument.

Fingerstick testing was performed by obtaining two separate fingerstick samples from each patient(n=34); one fingerstick sample was tested on ProTime5, the other on INRatio. The sameprocedure was used to compare fingerstick results on ProTime3 and INRatio (n=56 patients). Thereference INR from venous blood was obtained for all participants in the fingerstick evaluation.Fingerstick samples were independent and unique for each POC assay tested. No randomizationwas employed.

Linear regression, bias and outlier analyses were used to assess agreement between each POCsystem and the lab reference. Bias (relative differences between each POC system and thereference) and outlier analyses were performed with data separated into two INR classes, <2.5and > 2.5. This arbitrary INR separation was established to provide study balance for meaningfulevaluation. Classification was determined by lab reference system (MLA-Innovin) where INRvalues ranged from 0.91 to 4.76 for the study. Paired differences [POC-reference] were categorizedby agreement within 0.4 INR, and as discrepant by 0.7 or 1.0 INR. INR differences of 0.4 and 0.7have been used as benchmarks in comparative evaluations of the prothrombin time test1.Clinically significant inter-laboratory variations in INR have been documented in severalstudies2,3,4,5; 0.4 INR is considered acceptable variation1, based on the negative impact on clinicaldecision.

Pooled SD, which provides a measure of precision, was calculated using duplicate resultscollected with ProTime3 and INRatio. ProTime5 was not included in the precision evaluation asthe ProTime5 cuvette performs triplicate PT tests and reports the median value. ProTime3 andINRatio are more analogous in that each cuvette or test strip performs a singlet PT test.

RESULTS & DISCUSSION – ACCURACY WITH VENOUS SAMPLES

Regression analyses were performed to compare each POC system with the lab reference(Table 1, Figure 1). All three systems were highly correlated to the lab reference system withcorrelation coefficient (r) = 0.96, 0.93, and 0.96 for ProTime5, ProTime3 and INRatio, respectively.However, slope values varied among POC systems. INRatio vs. Reference produced a slope=1.40,indicating a strong positive bias to the laboratory system, while ProTime5 and ProTime3 bothgenerated slopes closer to 1.0, suggesting small or no bias.

Table 1: Regression Analysis, POC vs. Reference System, Venous Samples

POC System n slope intercept r

ProTime5 36 0.96 0.31 0.96ProTime3 37 0.90 0.27 0.93INRatio 36 1.40 -0.36 0.96

Figure 1 – Accuracy using Venous Samples, All POC Methods vs. Reference

Correlation: POC vs. Reference System

0

1

2

3

4

5

6

7

0 1 2 3 4 5 6 7

Reference System INR

PO

C IN

R

ProTime 5 ProTime 3 INRatio

Linear (ProTime 5) Linear (ProTime 3) Linear (INRatio)

Table 2 summarizes relative differences for each system. Differences calculated for the populationwere lower for both ProTime assays as compared to INRatio. Analysis of variance (ANOVA) wasperformed to statistically compare the POC methods to the lab reference system. Both ProTimeassays demonstrated statistical equivalence. INRatio results were significantly different (p<0.05).ANOVA findings were consistent for both INR ranges. Table 2 also shows how frequently eachPOC system was in agreement with the lab reference within 0.4 INR. For values <2.5 INR, bothProTime assays were within 0.4 INR of the lab reference 82% of the time while INRatio was inagreement less frequently (68%). Frequency of agreement was somewhat diminished withProTime3 for values > 2.5. INRatio frequency of agreement dramatically decreased for values > 2.5such that agreement with the lab reference was within 0.4 only 14% of the time.

Table 2: Bias Analysis [POC-Reference System], Venous Samples

ProTime5 ProTime3 INRatio

n 22 22 22

population avg. (INR) 2.1 1.9 2.2avg. relative difference vs.Reference 0.20 0.03 0.35**

SD of difference 0.19 0.29 0.28

<2.5 INR*�� within 0.4 INR (n, %) 18 (82%) 18 (82%) 15 (68%)

n 14 15 14

population avg. (INR) 3.3 3.3 4.1avg. relative difference vs.Reference 0.20 0.01 0.80**

SD of difference 0.28 0.38 0.53

> 2.5 INR*�� within 0.4 INR (n, %) 12 (86%) 10 (67%) 2 (14%)

*INR classification determined by Reference System result** Statistically significant difference (p<0.05) when compared to the Reference System

Table 3 identifies values for each POC system that disagreed with the reference system by greaterthan 0.7 and 1.0 INR. Almost no discrepant results occurred with the ProTime assays whileINRatio yielded numerous outliers.

Table 3: Discrepant INR Results [Comparison of POC and Reference Lab System], Venous Samples

ProTime5 ProTime3 INRation 22 22 22values discrepant by > 0.7 INR (n, %) 0 (0%) 0 (0%) 4 (18%)

<2.5 INR

values discrepant by > 1.0 INR (n, %) 0 (0%) 0 (0%) 1 (5%)n 14 15 14values discrepant by > 0.7 INR (n, %) 0 (0%) 1 (7%) 6 (43%)

> 2.5 INR

values discrepant by > 1.0 INR (n, %) 0 (0%) 0 (0%) 5 (36%)

RESULTS & DISCUSSION – ACCURACY WITH FINGERSTICK SAMPLESProTime3 vs. INRatio

Regression analyses were performed to compare both POC systems with the lab reference(Figure 2). Both were highly correlated to the laboratory reference with correlation coefficient(r) = 0.92 and 0.97 for ProTime3 and INRatio, respectively. Slope values were different betweenthe two systems. Slope=1.32 for INRatio, whereas slope=0.89 for ProTime3. These slopes weredirectionally consistent with venous sample testing on each system.

Figure 2 – Accuracy using Fingerstick Samples, ProTime3 and INRatio vs. Reference Lab System


ProTime3 n=51y = 0.89x + 0.23, r= 0.92

INRatio n=49y = 1.32x - 0.37, r=0.97

0

1

2

3

4

5

6

0 1 2 3 4 5 6


PO

C IN

R

ProTime 3 INRatio Linear (ProTime 3) Linear (INRatio)

Relative differences are summarized in Table 4. Differences calculated for the population weresmaller with ProTime3 in both INR classifications. Table 4 also shows the frequency of agreementfor each POC system relative to the lab reference result within 0.4 INR. Agreement with the labreference system was less frequent in the higher INR range for both POC systems. ProTime3demonstrated a greater percent agreement with the lab reference system in both INRclassifications. An ANOVA was performed to compare the POC methods with the lab referencesystem. ProTime3 demonstrated statistical equivalence in both INR ranges. INRatio differenceswere statistically significant (p<0.05) for INR values > 2.5.

Table 4: Bias Analysis [POC-Reference System], Fingerstick Samples, ProTime3 and INRatio

ProTime3 INRatio

n 39 38

population avg. (INR) 1.7 1.9avg. relative difference vs.Reference 0.02 0.17

SD of difference 0.23 0.19

<2.5 INR*�� within 0.4 INR (n, %) 35 (90%) 33 (87%)

n 12 11

population avg. (INR) 2.9 3.7avg. relative difference vs.Reference -0.16 0.62**


> 2.5 INR*�� within 0.4 INR (n, %) 5 (42%) 3 (27%)


Table 5 identifies values for each POC system that disagreed with the lab reference system bygreater than 0.7 and 1.0 INR. No such discrepant results occurred with the ProTime3 whileINRatio yielded several discrepant results in the higher INR range.

Table 5: Discrepant INR Results [Comparison of POC and Reference System], Fingerstick Samples,ProTime3 and INRatio

ProTime3 INRation 39 38values discrepant by > 0.7 INR (n, %) 0 (0%) 0 (0%)

<2.5 INR

values discrepant by > 1.0 INR (n, %) 0 (0%) 0 (0%)n 12 11values discrepant by > 0.7 INR (n, %) 0 (0%) 4 (36%)

> 2.5 INR

values discrepant by > 1.0 INR (n, %) 0 (0%) 2 (18%)

RESULTS & DISCUSSION – ACCURACY WITH FINGERSTICK SAMPLESProTime5 vs. INRatio

Regression analyses were performed to compare both POC systems with the reference lab system(Figure 3). Both were highly correlated to the reference system with correlation coefficient(r) = 0.97 and 0.98 for ProTime5 and INRatio, respectively. Slope values were different betweenthe two systems. INRatio produced slope=1.25 whereas ProTime5 generated slope=0.99. Asexpected, these slopes are directionally consistent with those observed with venous samples oneach system.

Figure 3 – Accuracy using Fingerstick Samples, ProTime5 and INRatio vs. Reference Lab System


ProTime 5 n=32y = 0.99x + 0.09, r=0.97

INRatio n=28

y = 1.25x - 0.22, r=0.98

0

1

2

3

4

5

6

0 1 2 3 4 5 6


PO

C IN

R

ProTime 5 INRatio Linear (ProTime 5) Linear (INRatio)

Relative differences are summarized in Table 6. Differences were smaller with ProTime5 in bothINR classifications. Table 6 also shows frequency of agreement for each POC system compared tothe lab reference result within 0.4 INR. Agreement with the lab reference system was less frequentin the higher INR range for both POC systems. ProTime5 demonstrated significantly closeragreement with the lab reference system, overall, in both INR classifications. An ANOVAcomparing the POC methods to the lab reference system demonstrated ProTime5 was statisticallyequivalent in each INR range. INRatio differences were statistically significant (p<0.05) for INRvalues > 2.5.

Table 6: Bias Analysis [POC-Reference System], Fingerstick Samples, ProTime5 and INRatio

ProTime5 INRatio

n 23 22

population avg. (INR) 1.55 1.70avg. relative difference vs.Reference 0.06 0.21


<2.5 INR*�� within 0.4 INR (n, %) 22 (96%) 17 (77%)

n 9 6

population avg. (INR) 3.13 3.57avg. relative difference vs.Reference 0.08 0.46**

SD of Difference 0.34 0.42

> 2.5 INR*�� within 0.4 INR (n, %) 7 (78%) 3 (50%)


Table 7 identifies values for each POC system that disagreed with the lab reference system bygreater than 0.7 and 1.0 INR. ProTime5 generated fewer discrepant than INRatio.

Table 7: Discrepant INR Results [Comparison of POC and Reference Lab System], FingerstickSamples, ProTime5 and INRatio

ProTime5 INRation 23 22values discrepant by > 0.7 INR (n, %) 0 (0%) 1 (5%)

<2.5 INR

values discrepant by > 1.0 INR (n, %) 0 (0%) 0 (0%)n 9 6values discrepant by > 0.7 INR (n, %) 1 (11%) 1 (17%)

> 2.5 INR

values discrepant by > 1.0 INR (n, %) 0 (0%) 1 (17%)

The percentage of discrepant values noted for the INRatio assay varied with the multiplefingerstick evaluations (36% and 17%). This may be explained by the smaller population tested inthe second study (n=56 and n=34) or lot-to-lot variation of the INRatio assay.

RESULTS & DISCUSSION – PRECISION

Duplicate results were obtained by testing venous blood samples with two ProTime3 and twoINRatio instruments. Pooled standard deviation (pooled SD) was calculated. Results aresummarized in Table 8. ProTime3 demonstrated a lower pooled SD than INRatio.

Table 8: Summary of Precision

ProTime 3 INRation (number of patients ) 36 35population avg. (INR) 2.4 3.0pooled SD 0.24 0.37

RESULTS & DISCUSSION – “NO RESULT” RATE

During the conduct of this study, no result was obtained periodically due to various test errors.Table 9 summarizes for each POC system the rate at which no result was reported during theaccuracy evaluations. ProTime errors were a combination of sampling (not enough blood),internal control and technical system errors. Almost all INRatio errors were related to sampling(not enough blood). “No result” rate was lower for both ProTime assays compared to INRatio.

Table 9: Summary of “No Result” Rate.

ProTime3 ProTime5 INRatio

tests (n)no result

(n) tests (n)no result

(n) tests (n)no result

(n)

Venous study 37 0 37 1 37 1Fingerstick study (1) 56 5 (n/a)� 56 7Fingerstick study (2) �(n/a)� 34 2 34 6TOTALS 93 5 71 3 127 14% Incidence, NoResult 5.4% 4.2% 11.0%

CONCLUSIONResults demonstrate all POC systems were highly correlated to a standard laboratory referencemethod. The slopes generated from the regression analysis show directional differences of theProTime and INRatio systems relative to the MLA. INRatio demonstrated a positive bias that wasexaggerated in the higher INR range resulting in significantly different results compared to theMLA for INR values > 2.5. The ProTime Microcoagulation System (ProTime5 and ProTime3)demonstrated a smaller bias and accurate INR results across the entire INR range, with fewdiscrepant values, consistent with published reports6,7. Results confirm both ProTime assays areappropriate for monitoring the coagulation status of patients on oral anticoagulant therapy. It isimportant that all sites establish their own correlation with the local laboratory to identifyinstitutional variation between POC systems and their unique reference systems.

REFERENCES

1 Lassen, J.F., Brandslund, I. and Antonsen, S. (1995) International Normalized Ratio forprothrombin times in patients taking oral anticoagulants: Critical difference andprobability of significant change in consecutive measurements. Clin. Chem. 41 (3) 444-447

2 Becker, D.M., Humphries, J.E., Walker, F.B., Demong, L.K., Bopp, J.S. and Acker, M.N.(1993) Standardizing the prothrombin time: Calibrating coagulation instruments as wellas thromboplastin. Arch. Pathol. Lab. Med. 117 602-605

3 Preston, F.E. (1995) Quality control and oral anticoagulation. Thromb. Haemost. 74 (1)51-520

4 Ng, V.L., Levin, J., Corash, L. and Gottfried, E.L. (1993) Failure of the InternationalNormalized Ratio to generate consistent results within a local medical community. Am.J. Clin. Pathol. 99 689-694

5 Horsti, J., Uppa, H., Vilpo, J.A. (2005) Poor Agreement among Prothrombin TimeInternational Normalized Ratio Methods: Comparison of Seven Commercial Reagents.Clin. Chem. 51 (3) 553-560

6 Oral Anticoagulation Monitoring Study Group* (2001): Point of care prothrombin timemeasurement for professional and patient self-testing use. Am J Clin Path 115: 288-296(*Group consists of Maureen Andrew, M.D., Jack Ansell, M.D., Daniel Becker, M.D.,Richard Becker, M.D., Douglas Triplett, M.D.)

7 Oral Anticoagulation Monitoring Study Group* (2001): Prothrombin time measurementusing a patient self-testing system. Am J Clin Path 115: 280-287. (*Group consists ofMaureen Andrew, M.D., Jack Ansell, M.D., Daniel Becker, M.D., Richard Becker, M.D.,Douglas Triplett, M.D.)

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