IMMULITE® 1000 Immunoassay System Kit Entry and Adjustment Online Training

Guidelines for acute therapy of ischemic stroke that were updated in 2009 recommend intravenous lytic therapy using rtPA within a 4.5-hour window after the onset of symptoms since a European stroke study confirmed significantly improved outcomes for patients even when the treatment is started between 3 and 4.5 hours after the onset of symptoms. However, treatment with rtPA beyond the 3-hour time window is not yet approved in Europe, so it can only be performed in the context of single patient use. Mr. Smith then undergoes intravenous lytic therapy. He receives intravenous rtPA for a period of about 60 minutes. The dosage is determined based on his body weight. Before treatment, contraindications need to be ruled out by the physician. Welcome to the IMMULITE® 1000 Immunoassay System Kit Entry and Adjustment Online Training course.  This course introduces you to: The critical procedures of loading kit components The required steps to perform adjustments The guidelines used to validate an adjustment Select Next to continue. Describe how adjustment is part of the calibration process Describe how to scan kit barcodes Identify kit components List the adjustment validation guidelines List the steps to load reagents List the steps to process adjustors Upon successful completion of this course, you will be able to: Select Next to continue. Congratulations. You have completed the IMMULITE 1000 Immunoassay System Kit Entry and Adjustment Online Training course.  Listed below are the key points that have been presented.   Take time to review the material before you proceed to the final quiz. Key Points In this online training course, you learned how to:   Identify kit components Kit Barcodes - The kit barcodes are located on the box flap inside the kit and must be entered the first time a kit lot is used. Instructions for Use - Contains specific information regarding the assay, including how to handle and store kit components. Important Notice - Contains information regarding usage of the assay kit components. Reagent Wedge - Should not be stored onboard the reagent carousel.  After being opened, the stability is 30 days. Test Units - Contain assay-specific beads, which are the solid phase of the reaction. Each bag contains 25 test units and a dessicant.  Adjustors - Each kit contains one or two adjustors. Kits with two adjustors have a low and a high adjustor. The adjustor can be in either liquid or lyophilized form. Describe how to scan kit barcodes Kit barcodes must be scanned before loading beads and reagents from a new kit lot onto the system.   Select the Kits button from the horizontal toolbar. Scan in each of the four kit barcodes on the inside flap of the kit box. The information for that kit lot displays on the Kit screen. List the steps to load reagents Remove the reagent tray from the reagent chamber. Load each wedge into the Reagent Tray by inserting the tab at the bottom of the wedge into the slot on the outer rim of the Reagent Tray. Place the reagent tray into the Reagent Chamber by positioning the reagent tray so the white line on the tray handle is aligned with the line on the tray spindle. Open the caps on the wedges and snap them down into position. When starting a new wedge, remove the foil seal. Then check the surface of the liquid for bubbles. Close the Reagent Carousel lid.   Press GO on the Display Panel.  List the steps to process adjustors Select the Worklist button. Select the Adjustor button. Enter the appropriate information in the available fields. Select the Accept button. Load the adjustor sample cups with four test units for each level on the load chain.   Describe how adjustment is part of the calibration process Calibration on the IMMULITE 1000 system requires scanning in the kit barcode (includes the master curve information) and running the adjustors.  List the adjustment validation guidelines QC results obtained after an adjustment should fall within the laboratory expected range and should not show a consistent large bias.  The Slope of the adjustment needs to be evaluated.  If it is an initial adjustment, the slope should fall within the instrument’s slope range.  If it is a re-adjustment, the slope should fall within plus or minus ten percent of the previous slope for that assay. The adjustment Intercept needs to be evaluated.  If the absolute value of the intercept exceeds the intercept guideline, QC results should be used to determine if the adjustment is valid.   Select Next to continue.  The components that make up an IMMULITE 1000 system kit include the following: IFU (Instructions for Use) Kit Barcodes Test Units Reagent Wedge Adjustors  NOTE:  Some kits will also have kit-specific controls included in the kit (for example, Insulin and some infectious disease kits).   Kit Components Learn about kit components. Base ImageHotspotsText BlocksImage File Kit Barcodes The kit barcodes are located on the box flap inside the kit.  Information specific to the kit lot is included in the kit barcodes.  The kit barcodes must be entered the first time a kit lot is used.    Reagent Wedge  A barcoded reagent wedge contains an assay-specific enzyme conjugate. During test processing, the reagent is pipetted into the test unit. Reagent wedges are not intended to be stored onboard the reagent carousel.  The reagent carousel is cooled, but not at refrigerator temperature.  Reagent wedges can stay onboard for up to 8 hours while they are used, but should be capped and returned to the refrigerator when the daily work is finished. The stability of reagent wedges is 30 days after they are opened.     IFU  The Instructions for Use (IFU) contain specific information regarding the assay, including how to handle and store kit components. It is good practice to read the IFU before using a new kit.   Test Units  Test units contain assay-specific beads, which are the solid phase of the reaction. The test unit serves as a reaction vessel in which the immune reaction, incubation, wash, and signal development processes occur. Each bag contains 25 test units and a desiccant.    Adjustors  Each kit contains one or two adjustors. Kits with two adjustors have a low and a high adjustor, which contain different concentrations of the analyte. The adjustors can be in either liquid or lyophilized form.   Before using a new kit lot, the kit barcodes for the new lot must be entered in the Kits screen using the hand-held barcode scanner.  The kit barcodes should be scanned in order before loading the reagent from the new lot onto the system.   Scanning Kit Barcodes Learn how to scan kit barcodes. Instructions:If media does not automatically start, select the play arrow to begin. Flash File:/content/generator/Course_90005446/sim_IM1_ScanKitBarcodes__9/sim_IM1_ScanKitBarcodes__9.swfHTML5 File:/content/generator/Course_90005446/sim_IM1_ScanKitBarcodes__9/index.htmlPDF File: For the interventional treatment of stroke, a C-arm system is always required, preferably one with two C-arms (biplanar). The Siemens Artis zee family offers cutting-edge C-arm systems with excellent resolution – which is critical for the exact placement of catheters. syngo DynaCT generates 3D images similar to CT using the C-arm. These support the preparation and planning of the procedure as well as the final verification and documentation of the treatment results, directly in the intervention room. Using syngo InSpace 3D, the vascular situation can be very precisely analyzed using the 3D images, and the best working projection can be determined. The syngo iPilot function supports catheter placement. It can overlay the 3D image and the live image. This makes it possible to compare the catheter position with the course of the vessel without injecting additional contrast agent. After successful revascularization, the achieved status is documented using syngo iFlow images (2D), and blood volume distribution is documented using syngo Neuro PBV IR (3D). A reagent wedge must be loaded on the system for each test being run. If a reagent wedge needs to be loaded while the system is processing samples, the system should be put into pause before opening the reagent carousel cover. Loading Reagent Wedges Learn how to load reagent wedges.   Select the play arrow to begin video.    When complete, select the X in the upper-right-hand corner to close the window and continue.     Specialized units can only ensure the optimal care of stroke patients if they meet certain requirements. Since the term “stroke unit” is not protected by law, many countries have developed certification systems. The certificate is awarded to stroke units that adhere to defined quality guidelines. Some of the criteria that must be met to receive the certificate in Germany are listed in the table. In the US, more than 600 certified stroke units existed in 2009, while Germany had about 200 in 2010. In Germany, about two thirds of stroke patients can be treated on a stroke unit. Services vary greatly by region, however – in the whole of Europe, an average of only 7% of stroke patients are treated in stroke centers. The availability of stroke units is not the only relevant factor, however; another is the patient's referral to such a specialized unit. To increase stroke awareness, educational programs are held for the general population, and training is provided to ambulance staff and emergency physicians.  Running adjustors is part of the calibration process on the IMMULITE 1000 system.  The system uses the results from the adjustors to calculate patient results. Calibration and Adjustment Learn about the calibration and adjustment process. Slide NumberText BlocksCalloutsAudio ScriptImage File1 Calibration and Adjustment Calibration on the IMMULITE 1000 System is a two-step process: 1. Master Curve Established by the manufacturer Encoded in the kit barcode Concentration vs Signal 2. Adjustment  The result of running the low and high adjustors Master Curve CPS (counts per second) vs Customer CPS  Select Next to continue. Note: If audio does not automatically start, select the play arrow in the top left to begin.Calibration on the IMMULITE 1000 System is a two-step process. In the first step, a master curve is created. The master curve is a calibration curve generated by the manufacturer for every kit lot. A series of calibrators is run in many replicates on a master instrument at the Siemens site. Through the master curve, the relationship between concentration and signal is established. The information for the master curve is encoded in the kit barcode that is scanned into the customer’s instrument with each new kit lot. The master curve cannot be used on its own to calculate patient results because the master curve was generated on a different instrument than the one being run in the customer lab. There are subtle differences in the signal measurement from instrument to instrument. To compensate for these differences, an adjustment is performed, which is the second step of the calibration process. During an adjustment, the low and high adjustors are run on the instrument. The CPS, or counts per second, results of these adjustors are compared with the master curve adjustor CPS values from the kit barcode, and a relationship between master curve CPS and the instrument CPS is established. Select next to continue.2Adjustment Relationship The adjustment and master curve are used together to calculate results from CPS values generated by the instrument. The results from adjustors are used to create the relationship between master curve CPS and the customer’s instrument CPS.  This relationship can be described by a straight line, which has a slope and an intercept. When an unknown patient sample is run on the customer’s instrument, the instrument measures a CPS value from that sample.  The adjustment relationship is used to convert that customer CPS into a master curve CPS value.   In other words, the instrument determines what the CPS value for that unknown patient sample would be if that sample had been run on the master instrument.  Select Next to continue. Now we’ll look at how the adjustment and master curve are used together to calculate results from CPS values generated by the instrument. As we discussed on the previous slide, the results from adjustors are used to create the relationship between master curve CPS and the customer’s instrument CPS. This relationship can be described by a straight line, which has a slope and an intercept. When an unknown patient sample is run on the customer’s instrument, the instrument measures a CPS value from that sample. The adjustment relationship is used to convert that customer CPS into a master curve CPS value. In other words, the instrument determines what the CPS value for that unknown patient sample would be if that sample had been run on the master instrument. Select next to continue.3Master Curve After the master curve CPS for the sample has been calculated from the adjustment relationship, that CPS value is plugged into the master curve in order to obtain the concentration.  By using the adjustment curve to adjust the CPS signal, we are able to use the master curve directly to calculate the concentration result.  Select Next to continue. After the master curve CPS for the sample has been calculated from the adjustment relationship, that CPS value is plugged into the master curve in order to obtain the concentration. By using the adjustment curve to adjust the CPS signal, we are able to use the master curve directly to calculate the concentration result. Select next to continue.4Summary  In summary, calibration on the IMMULITE 1000 System is a two step process. In order to calculate accurate patient results, the system requires both a master curve and a valid adjustment. When complete, select the X in the upper-right to close the window and continue.In summary, calibration on the IMMULITE 1000 System is a two-step process. In order to calculate accurate patient results, the system requires both a master curve and a valid adjustment. The adjustment validation guidelines are used to decide whether or not an adjustment is valid.  The adjustment validation guidelines involve three steps:  Evaluating the controls Reviewing the slope Evaluating the intercept Adjustment Validation Guidelines Learn about adjustment validation guidelines. Slide NumberText BlocksCalloutsAudio ScriptImage File1Evaluating the Controls  The first and most important adjustment validation guideline is to evaluate the Quality Control results: Run QC samples every time adjustors are run. The QC results must be within laboratory expected limits. Select Next to continue.  Note: If audio does not automatically start, select the play arrow in the top left to begin.The first and most important adjustment validation guideline is to evaluate the Quality Control results. Quality control must be run immediately following an adjustment. The results obtained for the control samples should be within acceptable limits as established by the laboratory and should not show a consistent large bias toward either the upper or lower acceptable limits. This is the primary and most important means of validating an adjustment. Select next to continue.2Reviewing the Slope  The second guideline that we need follow is to evaluate the slope. The value for the slope can be found in the upper left portion of the Adjustment Report.  Select Next to continue.     Select the number to review the corresponding text.Callouts Slope The second guideline that we need follow is to evaluate the slope. The value for the slope can be found in the upper left portion of the Adjustment Report. Select next to continue.3Instrument Slope Range For an initial adjustment: Slope reflects matching instrument to master curve instrument Range: should fall within Instrument Slope Range   Select Next to continue. Select the number to review the corresponding text.CalloutsInstrument Slope RangeThere are two guidelines for determining if the slope is acceptable, depending on if the adjustment was an initial adjustment or a readjustment. An initial adjustment is the first time that kit lot is ever adjusted. Each instrument has an average slope, which is based on the slopes for all initial adjustments from all tests run on that instrument. The slope of an initial adjustment for any new kit lot should fall within plus or minus twenty percent of the instrument’s average slope. This range is referred to as the Instrument Slope Range, and is displayed on the Adjustment Report. Select next to continue.4 Previous Slope Range For a readjustment: Slope reflects changes in chemistry over time Range: should fall within +/-10% of the previous slope for that assay  Select Next to continue.   Select the number to review the corresponding text. CalloutsPrevious Slope RangeEvery assay must periodically be readjusted, as indicated in the kit’s instructions for use, in order to correct for the reagent’s normal loss of activity over time. The slope from a readjustment should fall within plus or minus ten percent of the slope from the last adjustment for that kit lot. This range is referred to as the plus or minus ten percent of previous slope, and is displayed on the Adjustment Report. Select next to continue.5Using the Slope Range  If the slope is just outside of range: Adjustment is likely valid Verify that QC results are as expected Treat slope range as a “reference range”  Select Next to continue.Select each number to review the corresponding text.CalloutsLow end of slope rangeHigh end of slope rangeNow, let’s look at an example of applying the slope range to slope values from an adjustment. Remember, the adjustment validation criteria are called guidelines and not rules. In other words, if the slope is out of range, there might not be a problem, and therefore it doesn’t necessarily mean you should determine that the adjustment is not valid. In this example on an initial adjustment, the instrument slope range on the adjustment report is 0.77 to 1.15. Slope values that fall somewhat outside of this range may still be acceptable as long as the QC results are not biased in the same direction and the current slope is consistent with previous slopes for the same assay. For example, if the slope is 1.2 or 0.75, it is important to verify that the quality control sample results are not biased in the same direction. Treat the slope as a reference range, recognizing that results just outside the reference range do not necessarily mean something is wrong. Select next to continue.6Using the Slope Range  If the slope is slightly worse, adjustment may still be valid: If QC results are close to expected mean  If assay slope has historically been near the range limits  Select Next to continue. Select each number to review the corresponding text.CalloutsLow end of slope rangeHigh end of slope rangeIf the slope is a bit worse, for example 1.4 or 0.6, the adjustment may still be valid depending on several factors. If the quality control results are not consistently biased in the same direction and the slope for the assay has historically been near the same limit of the slope range, the adjustment is likely valid. Select next to continue.7Using the Slope Range  If the slope is less than 0.5 or greater than 1.8: There is a problem Adjustment is not valid, even if the QC results are acceptable Slope will be flagged by software  Select Next to continue. Select each number to review the corresponding text.CalloutsLow end of slope rangeHigh end of slope rangeA slope less than 0.5 or greater than 1.8 indicates a problem and the adjustment is not valid, even if QC is within range. In this case, the slope will be flagged by the software. Select next to continue.8Evaluating the Intercept  The last adjustment guideline involves evaluating the adjustment intercept. The intercept is located in the top right portion of the Adjustment Report.  Underneath the intercept, the Intercept Guideline is displayed. The absolute value of the Intercept printed on the Adjustment Report should be less than or equal to the Intercept Guideline.  Select Next to continue. Select each number to review the corresponding text.CalloutsInterceptIntercept GuidelineThe last adjustment guideline involves evaluating the adjustment intercept. The intercept is located in the top right portion of the Adjustment Report. Underneath the intercept, the Intercept Guideline is displayed. The absolute value of the Intercept printed on the Adjustment Report should be less than or equal to the Intercept Guideline. Select next to continue.9Using the Intercept Guideline  Guideline set to give an early warning Can result from normal assay imprecision during adjustment May increase over time due to increased non-specific binding as reagent ages Not necessarily rejection of the current adjustment Intercepts can also signal a problem Contamination of instrument / water  Problem with reconstitution of the adjustors Contaminated adjustor Impact is reflected in QC results  Check QC at low and high decision points For intercept exceeding guideline, final decision on accepting adjustment is based on QC  Select Next to continue. Select each number to review the corresponding text.CalloutsInterceptIntercept GuidelineThe intercept guideline indicates an early warning rather than a pass / fail criteria. Intercepts that exceed the intercept guideline do not necessarily indicate a failed adjustment. High intercepts may occur due to assay imprecision, even though the imprecision is within the assay specifications. In some assays, intercepts may increase over time due to increased non-specific binding as the reagent ages. It is rare for an adjustment to be considered invalid solely due to a high intercept. However, intercepts should always be monitored because an increased intercept can alert operators to other problems, such as contamination or issues with the adjustors. If the absolute value of the intercept exceeds the guideline, the final decision on accepting the adjustment should be based on the QC results. For example, it’s possible for adjustments with large intercepts to still be considered valid if the QC near the low and high decision points are acceptable and do not indicate biased results. Select next to continue.10Sandwich and Competitive Assays  Two types of immunoassays: Sandwich Assay: direct relationship between concentration and signal Competitive Assay: inverse relationship between concentration and signal To determine whether an assay is a sandwich assay or competitive one, refer to the instructions for use.  Large intercepts can affect the results for sandwich and competitive assays differently.   Select Next to continue.   Select each number to review the corresponding text.CalloutsSandwich AssayCompetitive AssayThere are two types of immunoassays: sandwich and competitive. To determine whether an assay is a sandwich assay or competitive one, refer to the instructions for use. A sandwich assay has a direct relationship between concentration and signal. In contrast, a competitive assay has an inverse relationship between concentration and signal. Large intercepts can affect the results for sandwich and competitive assays differently. Let’s take a look at some examples on the following slides. Select next to continue.11Impact of Intercept on Sandwich Assays Sandwich Assays - large intercepts affect the lower range of the assay before the higher end of the range. Select Next to continue. For a sandwich assay, a large intercept affects the lower range of the assay before it starts to affect the higher end. In this example, the intercept of an adjustment should be less than or equal to 10,570 CPS. The initial adjustment produced an intercept of 5,624 and the QC is within range as indicated on the slide. This intercept is acceptable. When the assay is readjusted, the intercept is equal to the intercept guideline and there is a 7% increase in the low level control. When the assay is adjusted the third time, the intercept increases to 15,855. Notice that there is a 13% increase in the low level control, but the high level control is still not affected. By the fourth adjustment, the intercept increases to 21,140 and now there is a 20% increase in the low level control and the high level control is only minimally affected. If an intercept exceeds the intercept guideline, and the QC bias is clinically significant, the adjustment should not be used, patient results should not be reported, and the problem should be investigated. Select next to continue.12Impact of Intercept on Competitive Assays Competitive Assays - large intercepts affect values across the range of the assay, especially those in the very high range of the assay. Select Next to continue. In a competitive assay, a large intercept can affect values across the entire range of the assay, with the most significant impact at the high end. In this example, the absolute value of the intercept should be less than or equal to 403,239 CPS. For the initial adjustment, the intercept is 18,750 and the QC is within range as indicated on the slide. This intercept is acceptable. When this assay is adjusted again, the absolute value of the intercept is equal to the intercept guideline and now there is a 24% increase in the high level control and a 9.8% increase in the low level control. When the assay is adjusted for a third time, the absolute value of the intercept is 604,859 and there is now a 42% increase in the high level control and a 15.5% increase in the low level control. On the fourth adjustment, the absolute value of the intercept is 806,478 and now there is a 65% increase in the high level control and a 22% increase in the low level control. Again, if the bias noted in the QC is clinically significant, the adjustment should not be used, patient results should not be reported, and the problem should be investigated. Select next to continue.13Summary  After we have a set of adjustment results, we use the adjustment validation guidelines to decide whether or not the adjustment is valid.  The adjustment validation guidelines involve three steps:  Evaluating the controls Reviewing the slope Evaluating the intercept When complete, select the X in the upper-right corner to close the window and continue.Let’s recap the three Adjustment Validation Guidelines. First, QC results obtained after an adjustment should fall within the laboratory expected range and should not show a consistent large bias. Second, the Slope of the adjustment needs to be evaluated. If it is an initial adjustment, the slope should fall within the instrument’s slope range. If it is a re-adjustment, the slope should fall within plus or minus ten percent of the previous slope for that assay. Last, the adjustment Intercept needs to be evaluated. If the absolute value of the intercept exceeds the intercept guideline, QC results should be used to determine if the adjustment is valid. Select the X in the upper-right corner to close the window and continue. Adjustments must be run: Before using a new kit lot. According to the adjustment frequency indicated in the IFU. To process adjustors:   Identify the adjustor sample cups in the Worklist Entry screen. Load the adjustor sample cups and test units on the load chain. Notes: The adjustor sample cups must be identified in the Worklist Entry screen before the adjustor sample cups are read at the barcode reader. Proper preparation, storage and handling of adjustor material is critical to achieving accurate results.  Refer to the IFU for information about each assay.   Sample Volume Requirements Learn more about determining sample volumes. The sample volume required varies with the assay to be run and the number of replicates requested on that sample.  The exact sample volume required for each test can be found in the corresponding instructions for use. For proper instrument operation, an additional dead volume is required, which is based on sample volume: Sample Volume Dead Volume Less than 100 µl 100 µl Greater than or equal to 100 µl 250 µl For adjustors, the total required sample volume would be four times the sample volume (since the adjustors are always run in replicates of four) plus the appropriate dead volume.   When complete, select the X in the upper-right corner to close the window and continue.   Adjustor Loading Learn how to load adjustors. For each level of adjustor, transfer the adjustor material to the appropriate sample cup according to the information that was programmed in the Worklist Entry screen for the adjustors.  Place the sample cup on the load chain followed by four test units for the assay being adjusted. NOTE:  There are assays that are qualitative.  Qualitative assays have a single adjustor (or calibrator) used to establish the relationship of the master cutoff to an individual instrument. When complete, select the X in the upper-right corner to close the window and continue.   Adjustor Sample Identification Learn how to identify adjustor samples. Instructions:If media does not automatically start, select the play arrow to begin. Flash File:/content/generator/Course_90005446/sim_IM1_IdentifyAdjustorSamples_9/sim_IM1_IdentifyAdjustorSamples_9.swfHTML5 File:/content/generator/Course_90005446/sim_IM1_IdentifyAdjustorSamples_9/index.htmlPDF File: