Automation in Clinical Chemistry

Automation
- it is a type of analysis that is automated
- automatically conducted procedures in the laboratory

TQM
- Total Quality Management
- 3 phases
1. Pre-analytical phase
- majority of the processes would still be done manually in the laboratory
a. Transport of sample
- MedTech’s, upon collecting the sample, they are the ones who will float the samples
from the receiving are going to the specific section of the laboratory
b. Identification of the sample
- majority of the errors observed and encountered in the lab is during the pre-analytical
phase
- as well as labeling and identification of samples
- labeling = right the name of patient, age, gender, date and time of collection and
identification of the individual that collected the sample using pens
- label being wet makes the label wash-out making the identification difficult
- incorporation of automation, we can easily eliminate possible sources of error
and increase the integrity of test we are doing
- ensure safety of patient and those handling the samples
2. Analytical phase
- analyzers that are automated
3. Post-analytical phase

History of Automation
- before 1950s, all the procedures done under the lab is done manually
- 1957 = introduction of 1st automated analyzers made by Technicon
- first generation do have downside
- this type of analyzer are considered to be CFAs (continuous flow analyzer)
- problem with CFAs is the carry overs, reagent and sample passes through
same tubing. The only one that separate sample from reagents and the one cleaning
the tubing is the presence of bubbles
 - another problem is that they can only do sequential analysis = regardless of
how many samples you load, it can only do single procedure or test for all those sample
placed in the analyzer
- not only it would consume time, there is no selectivity. Ex. Patient A needed
fasting blood sugar and lipid profile while patient B needed the same test but has
additional test for sodium/potassium and creatinine. All the sample will do the test of the
first sample.
- it makes the reagent be consumed more
- 1970 = introduction of centrifugal analyzer
- instead of being a CFA, they are the types of analyzers that conduct batch
analysis. Loading multiple samples, it would be doing the same test but only for those
who have requisition for that specific test
- unlike CFAs, we do not have selectivity, but for batch analysis, it will do the test
for the samples which is selected for the that specific type of test
- 1970 = introduction and production of ACA or Automatic Clinical Analyzer which is now
under the Siemens manufacture
- 1976 = mid year, the Dry technology has been introduced. The first one that employs
dry technology is the one produced by Vitros which is Kodak Ektachem
- 1980 = there has been the incorporation of different manners of identification of
analytes. Introduction of ISEs, fiber optics and polychromatic analysis. Since the first
generation are CFA conducting sequential analysis, next is centrifugal analysis which
conducts batch analysis. In this year, discrete analyzers are used. These analyzers are
the ones who have random access capability. Regardless if you have already input
multiple samples and selected tests to be done, if in case you have a stat request, you
can pause the previous test and prioritize the release and read of result for the sample
which is stat

Driving force toward more automation

1. Fast turn-around time
- manual pre-analytical phase consumes time (identification of patient, collection of
sample, labeling and transport) but with integration of automation during pre-analytical
phase specifically for those laboratory employing total laboratory automation
- you only do the collection of samples but the labeling and identification of the
sample are through bar coding and some utilizes RFID Tag labels which is more
advanced. The sample is being transported through the laboratory using conveyers
- during analytical phase, the sampling and releasing of result is not fully automated
2. Ease of use
- even though the lab worker undergo training
3. Precision, sensitivity and specificity
- decreased amount of errors
4. Walk-away capabilities and minimal operator intervention
- you can leave the work in the machine and not worry too much
5. Convenience for the patients (POC analyzers)
- majority of the analyzers are huge, but with the improvement of technology, point-of-
care testing can be done = they are portable and can be brought to patients
6. Higher volume of testing
- one of the major advantages
- true put = the number of tests or samples that could be run by a certain analyzer in an
hour
- 120 samples in 1 hour for fasting blood glucose compared to 3 manual test per hour

Modular Analyzers
- chemistry and immunoassays are incorporated to a single analyzer
- they are expensive but can have single machine but can conduct multiple test which
not only be limited to a single section of laboratory
- trend in automated analyzer that employs basic chemistry procedure, PCR testing and
certain immunoassay methodology
1. Siemens dimension Vista 500
2. Roche modular analytics
3. Abott architect ci8200
- private hospitals in the Philippines utilizes this machine
4. Beckman Coulter Synchron LXi 725

Steps in Automated Analysis

- in manual procedure, there are 3 different phases which is still applicable with
automated analysis. It will just depend on the analyzer present on the laboratory which
steps would be done manually and which steps will be done automatically
1. Specimen Preparation and Identification
- common evacuated tube used for chemistry test: most of analytes are being tested in
serum samples hence the one generally utilized for the collection is the non-additive
tube (red-stopper)
- red-top had 2 types:
- made up of glass = glass itself would be good activator of coagulation pathway
- made up of plastic = contains silica gel clot activator hence when samples are
collected, they need inversion to mix the clot activator to the sample
- 1 of the procedures in clinical laboratory analysis which still remains manual would be
specimen preparation and identification
> Pre-analytical specimen preparation has been and remains a manual process
- collection, label and retrieval of the samples which was already run in the
laboratory still remains manual but those that already employ total laboratory
automation, their collection is the only manual done. Their preparation and identification,
it is already automated
> for alternatives; since majority of errors fall under pre-analytical phase, if we have
already errors on this phase alone, we will have succeeding errors to two other phases.
A. use of robotics, or front-end automation
- we do have problems not only with the collection of the sample and the identification of
which specific evacuated tube must be utilized for certain procedures in the laboratory.
The most common evacuated tube utilized for chemistry test is the non-additive
evacuated tube, but there are certain procedures in the laboratory specifically in clinical
chemistry that utilizes anticoagulants. It is ideal for glucose determination to use sodium
fluoride in order to inhibit glycolysis.
- For our arterial blood gas determination, the ideal anticoagulant used would be
heparin
- For glucose monitoring, such as with HBA1C, we utilize EDTA
- even though we are encountering certain problems not only with the sampling itself but
also with the retrieval of serum.
- Ex; There are instances of fasting patient which is outpatient (not admitted in
the institution). Having request for fasting blood sugar and lipid profile, if both test are
combined, the fasting is being averaged which is at least 10-12 hours of fasting would
be required to the patient. After blood collection, the intern becomes too much confident
that the sample was correct. They instruct the patient to wait for 2 hours so that they
can get the results after the testing. After 20 minutes of letting sample coagulate before
centrifugation. After centrifugation, the sample was discovered to be hemolyzed.
Problems in hemolyzed sample are encountered in clinical chemistry most especially to
enzymatic procedure and colorimetric procedure would be employed for the
measurement of certain analytes. Upon the identification that the sample was
hemolyzed, they search in the out-patient department the patient itself. Upon reaching
the waiting area for OPD, the patient was already eating corn. The patient is not eligible
for sample collection since they have already eaten. Incident and problems occurred in
that situation. We cannot control even those that are already licensed can still collect
hemolyzed sample. There are still multiple factors that can make the sample hemolyzed
and since it is a major problem, one thing that we can do is the use of Whole blood
B. Analyze the whole blood sample
- SST = serum separator tube that has a gold stopper, we also have PST or plasma
separator tube
- we can collect that and identify the level of analyte using the PST
C. Use a plasma separator tube and perform primary tube sampling with heparin
plasma
> The sample must be properly identified, and its location in the analyzer must be
monitored throughout the test
- since in the automated machine today specifically the TLAs or the total laboratory
automation, they already utilize conveyer system. From the delivery of sample to the
specific analyzer that would be conducting the test that was requested on the test
menu, as well as with the centrifugation, separation of the liquid portion of the blood
from the packed red cells and to the retrieval and storage of our sample. For fully
automated machines, we could easily monitor and identify the location of the tube or
sample placed, the phase or testing, is it already done? Is it placed on the refrigerator
for storage? Or it is still under troubleshooting and running controls
- with our manual method, upon collection, the sample is delivered on the specific
laboratory, the medtech on duty will centrifuge the sample then the serum will be
separated through manual pipetting with the volume required for the specific test that
would be ran in the sample which depends on the requisition of the doctor. The storage
is typically in the work bench or in the working area. There are racks and the samples
are placed for those that are already tested. The problem with this is that when we need
to retrieve the sample of the patient, individually, the samples should be identified but
with the total laboratory automation, since the labeling is through barcoding with the fully
automated machines or RFID, the retrieval is being done using the computer or the LIS,
then the conveyer will place the sample back in the machine. No need for manual
searching for the sample and do further test depending on the request of the doctor.
> Means:
A. simplest and best way is through manual labeling
- even though barcoding system has been implemented, from the collection, we still
manually label the samples
B. Bar code (sophisticated approach) - contains patient demographics and may also
include test requests
- sophisticated approach to labeling is the bar coding system
- other uses RFID or radio frequency identification
- the greatest advantage of those samples that have RFID is that they are resistant
wear and tear. Even though the tubes has been wet the labels will be smudged through
alcohol or water. We will not have a hard time identifying the sample. Even if it is
exposed to cold temperature, the machine could still identify from which patient is this
sample from, what are the different tests that must be done within the sample and what
is the location of the sample in the machine

2. Specimen Measurement and Delivery

- depending on the manufacturer of the analyzer, they may have different racks for the
storage of our samples
> 2 common types of racks
- carousel or rectangular racks serves as specimen containers for disposable sample
cups or primary tubes in the loading or pipetting zone of the analyzers
1. Carousel form
- circular
- could handle more tubes or evacuated tubes and primary containers compared to the
rectangular racks
2. Rectangular racks
- the common models of those analyzers that have rectangular racks could only hold at
least 5 to 10 samples at the same time
> Cups and tubes hold standards, controls and patient specimen to be pipetted into the
reaction chambers of the analyzers
> Trays or racks move automatically in one position steps at preselected speeds (which
determines the no. of specimens to be analyzed per hour)
- for each of the sample, the arrangement on how the samples are placed would also be
the sequence on which sample would be run first. Since majority of the analyzers that
have carousel or rectangular trays are already discrete analyzers, there would random
access sampling or random-access analysis but the sequence on how we placed the
specimen, it would also be the sequence of running the test. Regardless of what
specific test has been selected to be run on that specific sample, it will be done first.
Afterwards, the test for the second sample would be administered.
> For convenience, the instrument has the capability to identify the last slot that contains
a specimen and terminates analysis after
- advantage of this feature is that it prevents the wastage of the reagents since the
machine could already identify that this specific section of the rack is the last one that
contains the sample, and has a test requested to be done. It could be prevented that the
machine would still be running without samples. Reagents would be safe as well as the
electricity
> The instrument's microprocessor holds the no. of samples in memory and aspirates
only in positions containing samples
- if in a case a spot was missed. Ex. chamber no. 3 was empty, the automated machine
could easily identify that chamber no. 3 doesn't contain a specific sample hence, it
would no cessate the testing but it would proceed to the next chamber that contains the
sample.
Racks
1. VITROS analyzer
- sample cup trays are quadrants that hold 10 samples in each cups with conical
bottoms
- carousel rack
2. Roche/Itachi
- the one that are produced by Roche or Itachi use 5 position racks to hold samples
- rectangular racks
3. Modular analyzers
- up to 60 at one time
> Aliquot is measured through aspiration of sample into a probe, and dispensed into the
reaction vessels
- in manual procedure, let the sample to clot since serum is the most commonly used
specimen in the laboratory. Then manually separate the serum from the primary
container to the secondary container or directly put the serum to the sample cell or
cuvette
- for fully automated machines, they already have the capability to aspirate the volume
needed for a specific analyte to be tested
- A single machine only has 1 probe. They are the ones aspirating the sample.
- Carry over, a commonly encountered problem with the CFAs or Continuous Flow
Analyzers wherein the reagents and sample flow in a single tubing.
- The probe has water reagent to prevent carry over
- How the probe works: the probe will go out of the machine then sample will be fed or if
fully automated, it would be retracting from the machine itself then puncture the
evacuated tube or if the sample is separated and has already been aliquoted, it would
directly aspirated the amount of serum needed for the testing
- to avoid carry overs, if it is retracting, when the probe goes back after the aspiration of
the sample, it will be rinsed using the water reagent making the carry over problem
eliminated. Even if there would be multiple samples to be tested at the same time,
problems will not be experienced with the results from one patient sample to another
> Probe and tubing are cleaned after each dispensing to minimize carryover, unless
disposable probes or tips are used.
- there are certain analyzers that uses reusable tips. There are analyzers that do not
utilize probes. If they are utilizing reusable tips, that is the only time that we will be
having problems with carryover.
- Ex. you have sample initially tested for FBS and the glucose level of that patient is
elevated. The next sample that you had fed to your machine also has request for FBS. it
is expected that the glucose level of this patient is normal but since we have utilized
reusable pipette tips or tips in the machine, there could be a possible carryover,
remnants of serum from the initial specimen fed which may cause a falsely increase or
elevated result for the next sample.

3. Reagent systems and delivery

- there are different types of reagents utilized in the laboratory, majority of the analyzers
nowadays have a ready to use type of reagent which are typically in liquid form
> Types of reagent
1. LIQUID: available in bulk volume containers or unit-doses
- these liquid reagents could easily be placed inside the analyzers and the analyzer
itself also has the capability to identify the level of the fluid
- there is no need for manual inventory
- not only with the sample which are barcoded, but also with the reagents, barcodes are
also placed in the reagents for easy monitoring, time and date of opening the specific
reagent, expiration date of the reagent, identify the volume or level of the reagent. There
are certain automated machines that do estimation
- Ex. the reagent is for creatinine and uric acid, on the display, there is an indication of
no. of possible test or samples that could possibly run to the volume present on the
reagent
2. Dry: bottled as lyophilized powder, requiring reconstitution or multi-layered dry
chemistry slide
- there are 2 types
a. Lyophilized powder = needs reconstitution. The powder needs to be mixed with buffer
or certain diluent so that it can be used for testing
b. dry technology = the reagent is incorporated to the multi-layered dry chemistry slide
> Preservation: refrigeration, reconstitution of dry tablet, or combination of two stable
components
- for fully-automated machines, since the reagents are placed inside the analyzers, most
could identify the volume of the reagent, this could help us identify the no. of test that
could be run with that volume
- the storage temperature required for the reagents could easily be maintained inside
the analyzer
- unlike with the manual procedure where we place the reagents depending on when we
will utilize it, we manually place them inside the refrigerator. If we need to use them, it
will consume time since we need to let the reagents rest at room temperature since we
cannot use them cold
> Dispensed via tubing from bulk containers, syringes that pipettes reagents into
reaction containers, piston-driven pumps connected by tubing, or pressurized reagent
bottles
- unlike in manual where we set the automatic pipette volume needed for the test even
with the incubation, we manually set it. Errors are eliminated in terms of correct pipetting
technique, dispensing of the sample volume needed as well as the reagent needed for
the specific test
> Multilayered dry chemistry slide for VITROS analyzer (KODAK Ektachem)
- it has multiple layers on the slide that are backed by a clear polyester support. The
coating itself is sandwiched in a plastic mount
3 Layers
a. A spreading layer = accepts the sample
b. One or more central layers = can alter the aliquot
c. Indicator Layer = where analyte of interest may be quantified

4. Chemical Reaction Phase

- in manual, after preparing the sample and reagent, incubate then mix with the reagent,
it will still be placed manually inside the spectrophotometer. There would still be multiple
factors that could affect the result that we could obtain from our testing. But with the
fully-automated analyzers, there has been an incorporation of the different steps
included in our chemical reaction phase
> Mixing: reagents and sample
- depending on the type of analyzer, the mechanism for mizing also differs
a. Coiled tubing (CFA)
- for continuous flow analyzers, air bubbles and coiled tubing is the mechanism for
mixing reagents and sample
b. Rapid start-stop of rotation or bubbling of air (centrifugal)
- the older generation of centrifugal analyzers employs air bubbles for mixing reagents
and sample
c. Mixing paddles (wet chemistry analyzers)
> Separation: separating undesirable substances from sample
- there are certain procedures that require the removal of protein specifically for non-
protein nitrogen. That initial step for NTNs would consume time. Conduct of additional
steps prior to the analysis of that certain target analyte should be done.
- But for chemical reaction phase, separation of unwanted or undesirable substances is
already automated since it was preset on the program of the machine.
- Ex. for urea, we need serum sample that is deproteinized, prior to the analysis, it
would already undergo the deproteinization procedure
> Incubation: heating bath (water or air) to maintain required temperature of reaction
time
- vary depending on the model of the analyzer
2 types of heating bath
a. Water bath
b. air bath
> Reaction time: depends on rate of transport through system and timed reagent
additions
5. Mixing
6. Separation
7. Incubation
8. Reaction Time
9. Measurement Phase
- in manual methodology, there are different basic principles that can be implemented
for measurement of certain analytes
- there are analytes that we can easily employ spectrophotometric methods, there are
some that needs chromatographic methods.
- For fully-automated machines, most of them would incorporate multiple principles for
the measurement of the analytes
> Systems for measurement include
a. Ion-selective electrodes
- ISE mainly utilized for electrolytes
b. Visible and UV light spectrophotometry (most common)
c. Fluorescence polarization (Abbott AxSYM), chemiluminescence, bioluminescence
d. Gamma counters
e. Luminometers

10. Signal Processing and Data Handling

- Prior to testing in the laboratory specifically in clinical chemistry, before conducting a
specific test, you need to conduct or run first a control
- With automated machines, early in the morning, the machine could be preset to run
the controls so that upon the arrival of the morning shift, they could proceed with the
analysis of different samples that were already obtained early in the morning
- for the releasing of the result, for the manual procedure and those laboratories that do
not employ LIS or Laboratory Information System, they manually type the results
obtained from the analyzers. Even the computation of the concentration of the specific
analyte, it is still being done manually
- But for those who have a bi-directional communication with the machine and the
computers specifically those that have LIS, the releasing of result could be done
paperless
- After rechecking if the specific test that were initially requested are already done, the
correct sample has been processed, the machine correctly perform test on the
appropriate chamber, there are no any problems or flats (there are values that would be
abnormally low or high) = for these instances, we need to assess the quality of the
sample followed by assessing the machine, afterwards, identify if the patient had
previous records. Results are not immediately released to the doctors.
> Accurate calibration is essential to obtain accurate information
- goal for quality assurance and quality control is that we produce accurate, precise and
reliable result
> Multiple instruments that measure the same constituent in a lab should be calibrated
so that results are compatible
> Automated instruments, once calibrated, provide long term stability of standard curve;
require only monitoring
- with manual quality control, we are not the only ones that place controls for testing but
also, we are the once who put the value and compute the value that we will be plotting
on the graph.
- for fully-automated machines, even the graphing and identification if there has been
any errors encountered will be shown on the display
> Some of the instruments are self-calibrating
> Advanced automated instruments have a method of reporting printed results and
communicating to LIS
> Computerized monitoring is available for many parameters

Selection of Automated Analyzers

> instruments evaluated should be rated according to previously identified needs
- we need to identify what is the need of the laboratory. If the laboratory is a secondary
laboratory, there is no need for sophisticated features of machine, there is no need that
it can run all the analytes
- there is a need to way the pros and cons of the different machines that are being
offered by a certain manufacturer
> Cost of the price of instruments and consumables
- assess the possible expenses not only with the cost of the machines you want to
procure, but also the consumables.
- It is expected that you will hand in large sums of money because you will invest for
automated machines
- one of the consumables is the reagent
> Calculate the total cost per test for each instrument that is considered
- there are certain analyzers that are open and closed reagent systems
> The ability to use reagents produced by more than one supplier (open vs close
reagent systems)
a. closed reagent system
- the manufacturer of the analyzer are the only ones that will provide the reagents that
will be used
- advantage: even though their reagents are more expensive compared to reagents for
open reagent system, we can preserve the integrity of the test. We will not encounter
problem since the analyzer is set for specific sensitivity for certain type of reagent there
could be no impurities with the reagent that would be procured
b. open reagent system
- use reagents produced by other vendors or manufacturers
- advantage: we have the ability to choose consumables that have lower prices as
compared to closed reagent system
> Labor component
- can still under consumables since for the maintenance of the machine, there would be
multiple parts that needs to be replaced and to identify if the laboratory workers are
capable to do the maintenance and troubleshooting alone or there is a need call for help
of experts or engineers coming from the manufacturer
> Instrument's analytic capability

Total Laboratory Automation

- a single section in the laboratory would already occupy a large room
- Ex. TLA for clinical chemistry would consume 3 laboratory rooms
- starting from the conveyer system, the area where the samples would be centrifuged
and separates aliquot then connected to different analyzers. All are interconnected with
a single conveyer system, then for storage for the samples that was already ran. The
conveyer is connected to the refrigerator for storage since for TLA, we have easy
retrieval of the samples

Pre-analytical phase (Sample Processing)

> Automated process replaces manual handling
> Key components
a. conveyance system
b. bar-coded specimen
c. computer software package to control specimen movement
d. coordination of robots with instruments as work cells
e. Automated sorting, centrifugation, uncapping, sample archiving, aliquoting
- one of the advantages of automation is that we not only ensure the safety of the
patients but also the safety of those that handles the sample
- there are instances that we need to uncap and recap the sample multiple times. When
capping and uncapping, it is considered as risk and a hazard to those that are handling
the samples
- There could be fumes that are released from the sample which could be inhaled by the
laboratory staffs

Analytic Phase (Chemical Analysis)

- most of the manual procedures employs lower volume of samples for the testing, for
fully-automated ones, there are some that only requires at least 20uL of the sample
> Ever-smaller micro sampling
- one of the greater advantages of fully-automated analysis
> Expanded onboard and total test menus
> Accelerated reaction times
> Higher-resolution optics
> Improved flow through electrodes
> enhanced user-friendly interactive software for quality control, maintenance, and
diagnostics
> Ergonomic and physical design improvements

Post-Analytical Phase (Data Management)

- there is an employment of the LIS
> Bi-directional communication between analyzers and host computer
- from the computer, we will set or select from the test menu the test needed to be done
in the sample then it would be controlled what specific part of the machine where the
sample is needed to be placed, what procedures or steps are needed to be done
- after analysis, the results that was obtained by the analyzers will be thrown back to the
compute. We can now easily see the result of the testing
- we can now easily identify if there are any flats or we could release the results
> Integration of work station managers into communication system
> Automated management of quality control data
> User-defined perimeters for many values
> Need for a "gap-filler" between instrument and laboratory information system
Future Trends in Automation
> Analyzers will continue to perform more cost-effectively and efficiently
- expect a faster turnaround time as compared to those that are already existing
- not only with the micro sampling that it would be cost-effective but also with the
consumables. There would be a smaller volume or amount of reagent required for use
for a single testing
> More integration and miniaturization of components
- since TLA consume more rooms, but with the improvement of the POCT analyzers,
expect that smaller machines could conduct more sophisticated type of test
> Sophisticated portable analyzers
> Expanded test menus (inclusion of more immunoassays and PCR-based assays)
- with the modular analyzers that are already existing, there could be an employment of
other test coming from the different section in the laboratory, not only limited with the
combination of chemistry test and immunoassays
> Spectral mapping, or multiple wavelength monitoring, with high-resolution
photometers in analyzers
> More system and workflow integration for robotics and data management
> incorporation of AI
- it is already possible
- the ones running the test are not medtechs, they can be only be placed in the
reception for the collection of the sample but all the other steps will be done by the
computer
> Technologic advances in chip technology and biosensors
- a chip will be placed inside the body of the person (prototype only). The specific chip
could easily identify the levels of different analytes that we test in the laboratory
- Replacement of manual methods and the automation for the analysis of analytes