Application of Techniques, Interpretation and Differential Diagnosis —
Training activity: 2

Details

Perform and interpret a full blood count and at least one other flow cytometry method

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Sample quality
• Acceptance testing – calibration
• Local SOPs
• Guidelines and standards, including EQA and IQC
• Maintenance and basic troubleshooting
• Reference intervals
• Impact on therapeutic option
• Downstream testing
• Limitations of the methods

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to performing and interpreting a full blood count and a flow cytometry method.
• Consider how the learning outcomes apply, specifically in relation to selecting, performing, and interpreting techniques, describing limitations, applying quality control principles, and communicating results.
• Discuss with your training officer to gain clarity of what is expected of you in terms of the interpretation of a full blood count and undertaking a flow cytometry.

What is your prior experience of this activity?

• Think about what you already know about performing full blood counts and flow cytometry, including instrument operation, sample requirements, and data analysis. Consider your prior experience interpreting results from these methods.
• Consider possible challenges you might face during the activity, such as instrument errors, sample issues, or interpreting abnormal results, and think about how you might handle them.
• Recognise the scope of your own practice for this activity, meaning knowing when you will need to seek advice or help e.g., for instrument maintenance, validation of abnormal results and from whom.
• Acknowledge how you feel about embarking on this training activity, especially if you are less familiar with flow cytometry.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, drawing upon previous experiences, which might include calibrating instruments, troubleshooting issues, or interpreting complex data plots.
• Identify specific insights you hope to gain from engaging with the activity, such as understanding the clinical significance of different parameters or how flow cytometry contributes to diagnosis.

What additional considerations do you need to make?

• Consult actions identified following previous experience of flow cytometry methods.
• Identify important information you need to consider before embarking on the activity, such as:
  • Reviewing the principles of flow cytometry and its applications in haematology.
  • Understanding the sample requirements and instrument operation necessary for performing a full blood count and flow cytometry method.
  • Reviewing how quality control principles apply specifically to instrument-based testing like full blood counts.
  • Identifying bioinformatic tools or software necessary for analysing complex data plots generated by flow cytometry.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate during the FBC analysis or flow cytometry run?
• Are you encountering situations such as:
  • An FBC analyser generating multiple critical flags or instrument errors e.g., scatter plot anomalies, reagent warnings that require immediate troubleshooting?
  • The flow cytometry data presenting unusual scatter plots or aberrant populations that do not correspond to the expected clinical picture or known disease markers?
  • The instrument exhibiting different behaviour or generating results that are outside the range expected based on previous experience or quality control data?
• How is this specific run or sample compare with previous experiences performing these tests?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to the analysis?
• Consider the steps you are taking in the moment, such as:
  • Immediately initiating troubleshooting steps for the analyser or re-checking sample integrity (e.g., checking for clots) before repeating the test?
  • Seeking immediate advice from a senior colleague regarding the interpretation of complex or aberrant flow populations that do not fit standard gating strategies?
  • Adapting your approach to data analysis e.g., adjusting gating parameters or reviewing raw data based on the unexpected instrument behaviour?
• How are you feeling in that moment? For instance, are you finding it difficult to adapt your technical knowledge to troubleshoot the instrument? Is it affecting your confidence in your ability to obtain valid results?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully mitigating a minor instrument error? Or are you needing support because the issue e.g., equipment malfunction or interpretation e.g., complex aberrant flow population falls outside your current scope?
• What are you learning as a result of the unexpected development? For example, are you learning a specific, efficient workflow for troubleshooting FBC instrument flags, or gaining crucial insight into the need for immediate escalation when sample integrity is compromised?

On action

What happened?

• Begin by summarising the key points of the experience of performing and interpreting the FBC and flow cytometry for this sample. What were the main steps involved from sample handling to data output, e.g., instrument setup, data acquisition, and primary data analysis?
• Consider specific events, actions, or results which felt important, such as troubleshooting instrument issues or encountering unusual scatter plot patterns during flow data acquisition. Include your own feelings during the experience.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, employing alternative analysis strategies e.g., reviewing raw data to investigate unexpected results or immediately consulting QC records due to instrument flags.

How has this experience contributed to your developing practice?

• Identify what learning you can take from the experience regarding instrument operation, QC application, or complex data analysis, e.g., refining your approach to troubleshooting instrument errors. What strengths did you demonstrate e.g., proficiency in initial gating strategies or instrument troubleshooting? What skills and/or knowledge gaps were evident e.g., unfamiliarity with specific data interpretation nuances (e.g., complex blast gating) or flow assay limitations?
• Compare this experience against previous FBC and flow cytometry activities – were any previous identified actions for development achieved? Has your practice improved?
• Identify any challenges you experienced e.g., troubleshooting instrument issues or interpreting complex flow cytometry data and how you reacted to these. Did this affect your ability to deal with the situation? Were you able to overcome the challenges?
• Identify anything significant about the activity. Did you need to seek advice or clarification regarding instrument performance, QC, or data interpretation? Did you need to escalate to ensure that you were working within your scope of practice?
• Acknowledge any changes in your own feelings now you are looking back on the experience.

What will you take from the experience moving forward?

• Identify the actions / ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received e.g., reviewing advanced flow cytometry principles or specific instrument SOPs.
• What will you do differently next time you perform or interpret FBC or flow cytometry? Has anything changed in terms of what you would do if you were faced with a similar situation again e.g., an instrument error or unusual scatter plot?
• Do you need to practise any aspect of the activity further e.g., specific gating strategies, troubleshooting steps?

Beyond action

Have you revisited the experiences?

• Have you reviewed your previous reflections for this activity? How does your understanding of FBC and flow cytometry interpretation compare now in light of subsequent experiences, especially regarding instrument performance or data QC?
• Have you had further opportunities to perform and interpret full blood counts and other flow cytometry methods since this activity? Were there similar or different challenges encountered with interpretation or technique, such as troubleshooting scatter plot anomalies?
• Can you recall specific instances in routine work where interpreting FBC or flow cytometry data was critical for patient investigation? For example, how did your experience in this training activity inform your approach when interpreting complex data plots for immunophenotyping
• Have you discussed FBC or flow cytometry interpretation with peers or colleagues? Did these discussions offer new perspectives on troubleshooting specific instrument errors or the clinical significance of certain findings?

How have these experiences impacted upon current practice?

• Has this activity improved your technical skills in performing FBC and flow cytometry methods and your confidence in interpreting the results?
• Do you now have a better understanding of the principles of these techniques and their limitations in different clinical scenarios?
• Has this experience influenced how you evaluate the quality control data associated with FBC and flow cytometry assays e.g., identifying when a run is acceptable for reporting?
• How will your experience with FBC and flow cytometry prepare you for working with different analysers or more complex flow cytometry panels in the future, supporting your potential involvement in specialised areas like CD34+ stem cell enumeration?

Relevant learning outcomes

#	Outcome
# 1	Outcome Select techniques for the investigation of clinical presentations in haematology, haemostasis and transfusion science and medicine.
# 2	Outcome Perform the laboratory techniques required for the investigation of clinical presentations in haematology, haemostasis and transfusion science and medicine.
# 3	Outcome Interpret the results of the laboratory investigations for cases including red and white cell disorders and haemostatic and platelet disorders, haematological malignancy and transfusion serology.
# 4	Outcome Describe the limitations of techniques applied in the investigation of clinical presentations in haematology, haemostasis and transfusion science.
# 5	Outcome Apply the principles of internal quality control and external quality assessment and draw conclusions about assay performance.
# 6	Outcome Demonstrate appropriate communication skills to present the results of investigations and cases clearly to healthcare professional colleagues.