Original article 569
Comparison of optical and mechanical clot detection for
routine coagulation testing in a large volume
clinical laboratory
Bing Baia, Douglas J. Christieb, Robert T. Gormanb and Jogin R. Wua
Hemostasis instrumentation has rapidly advanced and
laboratories are demanding fully automated coagulation
systems. Two distinct technological families exist based on
optical and mechanical clot detection methodologies. Until
now, there have been no comprehensive studies to
determine whether one methodology is superior to the
other. In order to answer this question, we conducted a large
clinical study performing standard coagulation testing on
more than 2000 clinical samples randomly chosen from a
high-volume laboratory in a tertiary care hospital. Results
demonstrated that photo-optical clot detection and electro-
mechanical detection systems were highly correlated (r-
squared values > – 0.96 for all assays) Correlation between
the two clot detection systems was maintained even when
measuring turbid samples (r-squared values > – 0.98 for all
Introduction
Because of the increasing demand for high-volume,
routine coagulation testing such as prothrombin time
(PT), activated partial thromboplastin time (APTT) and
Clauss fibrinogen (FIB), and the increasing challenge of
budget management, fully automated coagulation analy-
zers have become more and more popular over the last
decade. Clinical laboratories have a variety of choices in
automated coagulation analyzers today. Examples of
photo-optical analyzers include the ACL TOP, ACL
Advance (Beckman Coulter, Brea, California, USA),
MDA (Trinity Biotech, Berkeley Heights, New Jersey,
USA), BCS XP, and Sysmex CA-1500 (Dade Behring,
Deerfield, Illinois, USA). Examples of mechanical analy-
zers include the STA-R Evolution and STA Compact
(Diagnostica Stago, Parsippany, New Jersey, USA). The
AMAX Destiny (Trinity Biotech, Berkeley Heights, New
Jersey, USA) analyzer can measure clot formation in both
photo-optical and mechanical modes. It has been widely
held that mechanical clot detection is unaffected by turbid
samples and, hence, is superior to photo-optical detection,
which, in contrast, may be affected by turbid samples [1,2].
This has led to the belief that mechanical detection
provides a true clotting time (CT) determination for
coagulation testing. However, this contention is not
without controversy because of the technological advance-
ments in measurement algorithms for modern coagulation
analyzers. Some studies have suggested that optical and
mechanical detection methods are equivalent in terms of
0957-5235 ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
assays). Blood Coagul Fibrinolysis 19:569–576 ß 2008
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Blood Coagulation and Fibrinolysis 2008, 19:569–576
Keywords: clot detection, coagulation, mechanical detection, optical
detection
a
Department of Pathology, Duke University Medical Center, Durham, North
Carolina and bDepartment of Clinical & Scientific Affairs, Dade Behring Inc.,
Newark, Delaware, USA
Correspondence to Jogin R. Wu, PhD, Duke University Medical Center, DUMC
3514, 129C CARL Research Drive, Durham, NC 27710, USA
E-mail: jogin.wu@duke.edu
Received 31 October 2007 Revised 20 April 2008
Accepted 30 April 2008
correlation, accuracy and precision for coagulation testing,
and that both methods are unaffected by sample turbidity
[3–6]. However, these studies primarily focused on
the performance of one particular instrument/reagent
combination rather than a ‘standard’ instrument/reagent
combination as the comparative method. Further, turbid or
total sample numbers as a rule were small. Other studies
have suggested that optical detection is superior to mech-
anical detection [7–9], such as in a clinically important case
of dysfibrinogenemia caused by a familial mutation [10]
and a biphasic waveform that indicated a suspicious sepsis
patient [9]. Consequently, the advantage of one detection
method over the other remains unknown. Therefore,
we set out to determine the rates at which optical and
mechanical detection of coagulation fail to yield a measur-
able end point in routine patient samples in a high-volume
hospital setting, whether mechanical or optical detection
provides more reliable results as judged by the tilt
tube method using suboptimal samples (e.g. hyperbilir-
ubinemia, lipemia, etc.) and how to set the criteria for
‘performance of alternative procedures in the presence of
significant hyperbilirubinemia or lipemia, paradoxically
short APTTs and nonduplicating APTTs, in light of the
College of American Pathologists checklist on guidelines
for determining CTs [11]. It is anticipated that different
failure rates for detecting coagulation in samples will be
observed for optical and mechanical methods depending
on the nature of interfering factors. It is further expected
that by using the tilt tube test as the reference method it
 570 Blood Coagulation and Fibrinolysis 2008, Vol 19 No 6
will be possible to resolve discrepant results between the
optical and mechanical detection methods better.
Patient samples
All plasma samples were randomly selected from consecu-
tive patient samples obtained from the normal course of
the clinical laboratory’s daily routine for standard coagu-
lation testing. The laboratory is part of a high-volume
clinical setting at Duke University Medical Center, a
tertiary care hospital that requires rapid turn-around-time
in diagnostic testing for emergency room, operating room,
intensive care (ICU) and pediatric patients. All patient
samples were prospectively collected and tested for PT,
APTT and FIB following the laboratory’s routine proto-
cols for these assays. Patient samples were collected
by clean venipuncture using siliconized glass tubes
(Vacutainer Becton Dickinson, Franklin Lakes, New
Jersey, USA). Blood collection was performed with an
initial pilot tube that was discarded, followed by a second
tube (Becton Dickinson light blue tube) containing 3.2%
sodium citrate. For adult and pediatric patients, 4.5 ml and
a 1.8 ml tubes, respectively, were filled to the proper line
to guarantee that a sufficient volume of blood had
been drawn. Samples were immediately centrifuged at
3000 rpm (1500 g) for 15 min, and all samples were loaded
onto the laboratory’s primary coagulation instrument for
routine testing. Following these standard tests (PT, APTT
and FIB), between 50 and 100 samples per day were
randomly selected and immediately delivered to the study
instruments (STA and CA-1500). Inclusion criteria were all
routine plasma samples submitted for standard coagulation
testing. Test results for a particular method (e.g. FIB) were
excluded if there was insufficient sample volume for
analysis on both the CA-1500 and STA analyzers.
Materials and methods
The Sysmex CA-1500 (CA-1500) (distributed by Dade
Behring, Deerfield, Illinois, USA), a fully automated
photo-optical coagulation analyzer, was the test method
and the STA (Diagnostica Stago, Parsippany, New Jersey,
USA), a fully automated electromechanical coagulation
analyzer, served as the comparative method. To reduce
variability, only Dade Behring reagents were used on
the two test systems (CA-1500 and STA) and in tilt tube
testing. Innovin was used for PT, Actin FSL for APTT,
and Dade thrombin combined with Owrens Veronal buffer
for FIB. In addition, the Dade Behring standard human
plasma was used for calibration. The following materials
were used for the daily quality control: Dade Behring
Citrol level 1 (for PT, APTT and FIB method), Citrol
level 3 (for PT and APTT) and abnormal fibrinogen
control (for FIB method). Consumables used included
Sysmex reaction tubes, sample plates, CA Clean I and
II, deionized water and calcium chloride (CaCl2). For the
tilt tube method, supplies included a 378C water bath,
stopwatch, siliconized glass tubes and disposable pipettes.
For STA, all consumables such as STA cuvettes, STA
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
cleaning solution, Desorb solution, etc. were purchased
from Diagnostica Stago.
All three routine coagulation tests (PT, APTT and FIB)
were performed with both the test and comparative
method and, if necessary, the tilt tube method (described
below), within 4 h of receiving the sample. Residual
samples were aliquoted and frozen for future use. A total
of 2057 patient samples were included in the study during
a period of 45 days. The degree of visually observable
interference in study samples was characterized accord-
ing to a ‘Sample Integrity Chart’ (Ortho Clinical
Diagnostics, Johnson & Johnson Company, Rochester,
New York, USA), which provides semiquantitative
(hemoglobin up to 50 mg/dl, lipid up to 150 mg/dl and
adult bilirubin up to 5 mg/dl) and qualitative (slight,
medium or gross) grading based on color/cloudiness.
Whenever either gross turbidity was observed or no clot
resulted or both with either the test or the comparative
method, the tilt tube method was performed on the
remaining sample, if available.
Plasma from 25 normal healthy individuals was assayed to
obtain the geometric means and reference ranges for PT,
APTT and FIB for both the CA-1500 and STA instru-
ments, respectively, using EP Evaluator 6.0 software
(David G. Rhoads Associates, Inc., Kennett Square,
Pennsylvania, USA). Daily, weekly and monthly quality
control and maintenance were performed following the
manufacturers’ recommended procedures. All assays for
each patient sample were performed in singleton on each
analyzer and the tilt tube procedure, performed by
one expert technologist, within 4 h of blood collection.
Assaying samples on CA-1500 and STA was performed
within 1 h of each other and the tilt tube procedure not
longer than an additional hour. PT, APTT and FIB assays
were measured following the manufacturer’s package
insert instructions. For PT, 50 ml of patient sample was
incubated at 378C for 180 s, followed by the addition of
100 ml of Innovin reagent. For APTT, 50 ml of patient
plasma was incubated for 60 s and then mixed with 50 ml
of Actin FSL for another 240 s, followed by addition of
50 ml of CaCl2 to start the reaction. For FIB, the Dade
Behring standard human plasma and Dade thrombin
reagent were used to generate a standard curve and cali-
bration, from which calibration verification was performed
according to the manufacturer’s recommendations and the
laboratory standard procedure for the FIB test established
in this laboratory. The abnormal fibrinogen control and
Citrol level 1 were used for the FIB quality control.
Statistical methods
Mean, standard deviation (SD) and percentage coefficient
of variation were calculated for each assay. Contingency
tables were generated using the Statistical Analysis
System (SAS) System (version 8.02) to calculate the rate
of discrepant results of the two systems. Correlation and
 Clot detection for routine coagulation testing Bai et al. 571

Table 1 Intraassay precision of CA-1500 and STA in normal and abnormal control products (n U 20)
Normal control Abnormal controls

PT (s) APTT (s) FIB (mg/dl) PT (s) APTT (s) FIB (mg/dl)

CA-1500 STA CA-1500 STA CA-1500 STA CA-1500 STA CA-1500 STA CA-1500 STA

Mean 10.3 9.1 28.2 25.9 264.1 296.1 45.3 45.8 64.7 62.2 104.2 104.8
SD 0.1 0.1 0.1 0.1 12.6 3.3 0.3 0.8 1.2 0.7 9.0 2.4
CV (%) 0.7 0.9 0.5 0.5 4.8 1.1 0.7 1.8 1.9 1.2 8.6 2.3

APTT, activated partial thromboplastin time; CV, coefficient of variation; FIB, Clauss fibrinogen; PT, prothrombin time; SD, standard deviation.

regression analyses were performed on the assay results
using Analyze-it (version 1.67). A correlation coefficient
(r) value equal to 1.0 indicates a perfect correlation
whereas values less than 0.50 indicate a poor correlation.
Statistical significance was defined by a hypothesis test
yielding a P value of less than 0.05. The P value defines
a probability for how often the observed difference
would occur by chance variation if there really were
no difference.
Results
Reference ranges and precision
Plasma samples from 25 healthy normal donors yielded the
following reference ranges: for PT, 9.5–11.3 s and
8.3–10.4 s, respectively, for CA-1500 and STA; for APTT,
25.5–31.9 s and 24.5–31.8 s, respectively, for CA-1500 and
STA; and for FIB, 181–370 mg/dl and 216–378 mg/dl,
respectively, for CA-1500 and STA. Intraassay precision
for quality control products representing normal (within
reference range) and abnormal (within pathological range)
samples was performed by repeating the same sample in 20
individual tubes during the same run. Intraassay precision
results are shown in Table 1. For the normal controls,
CA-1500 and STA demonstrated a similar precision for
PT (0.7–0.9% coefficient of variation) and APTT (0.5%
coefficient of variation), whereas for FIB, precision for
CA-1500 and STA were 4.8 and 1.1% coefficient of vari-
ation, respectively. For the abnormal controls (in the
pathological range), both CA-1500 and STA had precision
for PT and APTT ranging between 0.7 and 1.9% coeffi-
cient of variation and for FIB, between 2.3 and 8.6%
coefficient of variation. Interassay precision was obtained
by testing both normal and abnormal controls for 30 con-
secutive days. Table 2 shows the interassay precision
results. Both normal and abnormal controls demonstrated
excellent interassay precision for all three assays well
within manufacturer’s specifications.
Sample summary
We randomly collected 2057 clinical samples from a rou-
tine high-volume clinical laboratory. As shown in Table 3,
among the 2057 samples, 2052 (99.8%) had PT results,
2034 (98.9%) had APTT results and 2023 had FIB results.
Five hundred and forty-six samples had visually observed
interferences due to hemolysis, lipemia, or icterus or
all three, as determined by the ‘sample integrity chart’
(see methods and materials).
Correlation between photo-optical and
electromechanical clot detection
Correlation was determined using more than 2000 clinical
samples over a 45-day time period. All three standard
coagulation assays were tested. Statistical analysis
demonstrated an excellent correlation between the
photo-optical and electro-mechanical analyzers for PT
(r ¼ 0.99), APTT (r ¼ 0.99) and FIB (r ¼ 0.98) (Table 4;
Figs 1–3). Because of differences in reagent sensitivity
to the vitamin K-dependent clotting factors (factors II,
VII and X) and in different reagent/instrument combi-
nations, the PT has been normalized to an international
normalized ratio (INR) to standardize the reporting PT
results for patients on stable oral anticoagulant therapy
(OAT). A local PT result is then converted to an INR
value, in which INR represents the prothrombin ratio
(patient PT/mean normal PT) raised to the power of an
international sensitivity index (ISI). The appropriate ISI
for the particular reagent used in the reagent/instrument
combination is determined by the responsiveness of the
PT reagent as compared with and graded against a
sensitive WHO international reference preparation

Table 2 Interassay precision of CA-1500 and STA in normal and abnormal control products (n U 30)
Normal control Abnormal controls

PT (s) APTT (s) FIB (mg/dl) PT (s) APTT (s) FIB (mg/dl)

CA-1500 STA CA-1500 STA CA-1500 STA CA-1500 STA CA-1500 STA CA-1500 STA

Mean 10.4 9.3 28.2 31.1 275.6 288.7 45.9 49.5 65.5 75.2 104.0 97.4
SD 0.1 0.2 0.4 0.6 9.5 7.3 2.0 1.5 2.5 1.5 9.0 4.1
CV (%) 1.4 1.8 1.5 1.9 3.5 2.5 4.3 3.0 3.8 2.0 8.7 4.3

APTT, activated partial thromboplastin time; CV, coefficient of variation; FIB, Clauss fibrinogen; PT, prothrombin time; SD, standard deviation.

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 572 Blood Coagulation and Fibrinolysis 2008, Vol 19 No 6

Table 3 Number of ‘no clot’ sample results by test method

No clot on STA and reported Reported result on STA No clot on both STA Excluded for insufficient
Test method Total sample sizea result on CA-1500 and no clot on CA-1500 and CA-1500 plasma volume

PT 2052 1 (0.0%) 0 (0.0%) 0 (0.0%) 4 (0.1%)

APTT 2034 5 (0.2%) 0 (0.0%) 13 (0.7%) 5 (0.2%)
FIB 2023 23 (1.1%) 5 (0.2%) 3 (0.1%) 3 (0.1%)

a
Varying sample sizes were due to lack of clot formation in certain assays as well as samples excluded for insufficient sample volume. APTT, activated partial thromboplastin
time; FIB, Clauss fibrinogen; PT, prothrombin time.

(IRP) of thromboplastin [12,13]. After the normalization
of PT to INR, the two detection methods yielded very
similar results (with slope of 0.99 and intercept of
0.02
INR units) and were highly correlated (P < 0.001)
(Table 4; Fig. 1). For APTT, CA-1500 yielded results
similar to STA at values below 40 s but slightly lower
absolute results when APTT values were above 40 s (due
to a slope of 0.86 and intercept of 4.92 s). Unlike the
normalized and widely used INR for PT results, there is
no standardized index for APTT, and each hospital has to
establish its own APTT sensitivity against heparin for its
use in monitoring patients under heparin therapy. For FIB,
the comparison of the two detection methods yielded a
slope of 0.96 and intercept of
16.58 mg/dl. Considering
that STA has a slightly higher reference range than
CA-1500, the two methods provided virtually identical
results over the entire analytical range (40–800 mg/dl).
Further analysis of the subgroup of turbid samples indi-
cated that the correlation remained strong between the two
detection methods (Table 5). Although there were several
samples in each assay that qualified as statistical outliers
(lying outside the 95% prediction interval), they were not
deleted from any of the regression analyses because they
were found to have no substantial effect on the results.
Discrepant results between the two methods were defined
as either ‘normal on STA and abnormal on CA-1500’ or
‘abnormal on STA and normal on CA-1500’. For PT and
APTT, ‘abnormal’ was defined as a CT result above the
reference range, and for FIB, ‘abnormal’ was defined as a
value below the reference range. As shown in Table 6,
overall, 0.2–2.3% of test results were reported as discre-
pant between the two methods.
‘No clot’ samples
For all three assays examined, any result that showed ‘no
clot’ was either printed as ‘error’ (STA), or ‘no coagu-
lation’ or ‘analysis time over’ (CA-1500). The number of
samples that showed ‘no clot’ by either method is shown
in Table 3. Although a total of 2057 samples were tested,
some were not included in the data set due to insufficient
volume for one of the three methods. For PT, among the
2052 samples tested, one sample yielded a ‘no clot’ error
on STA due to the fact that the upper limit of the PT
setting is 100 s on STA, whereas it produced results by
both CA-1500 (132.4 s) and the tilt tube (120.4 s) method.
For APTT, 2034 samples were tested, with five samples
showing ‘no clot’ on STA, whereas they provided results
with CA-1500. Among these five samples, one demon-
strated a regular clot and normal result by tilt tube (24.4 s)
and CA-1500 (24.3 s), whereas for the remaining four
samples, the tilt tube method showed longer CTs as
compared with CA-1500 (34.1, 213.8, 169.7, 200.4 s for
CA-1500 and 59.1, >300, 208.9, 241.4 s for tilt tube,
respectively). As shown in Table 3, in no case did
STA provide an APTT result whereas CA-1500 yielded
‘no coagulation’; although in 13 samples, the APTT
showed ‘no clot/no coagulation’ on both STA and CA-
1500, all of which also showed ‘no clot’ by tilt tube. For
fibrinogen, there were 2023 samples tested, with 23
samples showing ‘no value’ on STA yet yielding results
on CA-1500. Conversely, there were five samples that
showed ‘no value’ on CA-1500 but provided results on
STA. Only three samples had ‘no value’ for FIB on both
STA and CA-1500. The tilt tube method is not used for
assaying fibrinogen levels.
Samples with visually observed interferences
A total of 546 samples (26.5% overall) with visually
observed interferences were identified and tested on
STA, CA-1500 and tilt tube for PT, APTT and FIB.
All three assays showed a good correlation between the
comparative and test methods (Table 5 and Figs 4–6).
No clot was observed for 13 turbid samples on both STA

Table 4 Correlation analysis for all samples performed on CA-1500 and STA
Median (ranges) Reference ranges

CA-1500 STA Correlation (r) Slope (95% CI) Intercept (95% CI) Comparison (P) CA-1500 STA

PT (s) 10.6 (8.0–104.8) 9.8 (6.6–100.0) 0.99a 0.99a
0.02a <0.001 9.5–11.3 8.3–10.4
APTT (s) 29.4 (20.8–208.2) 28.6 (17.7–199.2) 0.99 0.86 4.92 <0.001 25.5–31.9 24.5–31.8
FIB (mg/dl) 344.8 (48.0–901.7) 369.0 (53.0–968.0) 0.98 0.96
16.58 <0.001 181.0–370.0 216.0–378.0

a
Regression based on INR units. APTT, activated partial thromboplastin time; CI, confidence interval; FIB, Clauss fibrinogen; INR, international normalized ratio; PT,
prothrombin time.

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Fig. 1
Correlation of international normalized ratio performed on STA and
CA-1500 (n ¼ 2052). The center line represents the regression line
between the STA and CA-1500 assay results, whereas the outer lines
represent the boundaries of the 95% prediction interval. Although
points lying outside the prediction interval can be considered outliers,
these points were included in the calculations as their effect on the final
results was negligible due to their locations and the large number of
patient samples. INR, international normalized ratio.
and CA-1500 for APTT. Three samples showed no clot
on both STA and CA-1500 for FIB. Discrepancies in
clotting results are enumerated for all three assays in
Table 6.
Fig. 2
Correlation of activated partial thromboplastin time performed on STA
and CA-1500 (n ¼ 2034). The center line represents the regression line
between the STA and CA-1500 assay results, whereas the outer lines
represent the boundaries of the 95% prediction interval. Although
points outside the prediction interval can be considered outliers, these
points were included in the calculations as their effect on the final
results was negligible due to their locations and the large number of
patient samples. APTT, activated partial thromboplastin time.
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Clot detection for routine coagulation testing Bai et al. 573
Fig. 3
Correlation of Clauss fibrinogen performed on STA and CA-1500
(n ¼ 2023). The center line represents the regression line between the
STA and CA-1500 assay results, whereas the outer lines represent
the boundaries of the 95% prediction interval. Although points outside
the prediction interval can be considered outliers, these points were
included in the calculations as their effect on the final results was
negligible due to their locations and the large number of patient
samples. FIB, Clauss fibrinogen.
Discussion
Detection of coagulation in plasma by mechanical metho-
dology relies on the formation of a clot detected by the
slowdown of an oscillating ball. Photo-optical method-
ology, on the contrary, assesses the time of clot formation
by measuring an increase in light absorption at a particular
wavelength [14,15]. The tilt tube method visually
measures viscosity changes upon the formation of cross-
linked fibrin [12]. The tilt tube method is regarded as the
‘gold standard’ for assaying the PT in assigning ISI values
using WHO reference materials [13] as well as the refer-
ence method for evaluation of either new assays or devices
or both for measuring CTs [6,16–18].
Our study was designed to determine whether the mech-
anical or photo-optical detection methods differ in deter-
mining CT for a given sample, using the tilt tube method
to resolve discrepancies. Our results show that photo-
optical and mechanical detection for routine coagulation
analysis (PT, APTT and FIB assays) are highly correlated
in 2057 samples tested over a 45-day time period in a
high-volume clinical laboratory of a large tertiary hospital
Table 5Correlation analysis for all turbid samples tested on
CA-1500 and STA
Correlation (r) Slope Intercept Comparison (P) Sample size (n)
PT (s) 0.98 0.99 0.85 <0.001 546
APTT (s) 0.99 0.80 6.61 <0.001 539
FIB (mg/dl) 0.98 0.97
21.06 <0.001 539
APTT, activated partial thromboplastin time; FIB, Clauss fibrinogen; PT, prothrom-
bin time.
 574 Blood Coagulation and Fibrinolysis 2008, Vol 19 No 6

Table 6 Discrepancy between test results obtained on the CA-1500 Fig. 5

and the STA analyzers for standard coagulation testing
Normal on STA Abnormal on STA
Total and abnormal on and normal on
Test results (n)a CA-1500, n (%) CA-1500, n (%)

PT 2052 20 (1.0) 47 (2.3)

APTT 2034 47 (2.3) 33 (1.6)
FIB 2023 4 (0.2) 12 (0.6)

a
Varying sample sizes were due to lack of clot formation in certain assays. APTT,
activated partial thromboplastin time; FIB, Clauss fibrinogen; PT, prothrombin time.

(Tables 4 and 5). In addition, we also observed that the two

methods generated similar reference intervals, SDs and
coefficients of variation. Even so, some differences were
observed between STA and CA-1500 (Table 6). A small
percentage of normal results as measured by STA were
borderline abnormal on CA-1500 (1, 2.3 and 0.2% for PT,
APTT and FIB, respectively). Similarly, a small percen-
tage of results were normal with CA-1500 but borderline
abnormal with STA (2.3, 1.6, and 0.6% for PT, APTT and
FIB, respectively). Except for a single statistical outlier in
each test (see details in the ‘discussion’), neither of which
occurred with a turbid sample, these discrepant values
were within 2.8 SD. In clinical practice, proper reference
ranges for PT and APTT are typically established with a
local normal donor group. In establishing such reference
ranges, certain diagnostic criteria must be met, including
sensitivity for various factor assays related to the ‘intrinsic’
and ‘extrinsic’ pathways to assure adequate differentiation
of normal coagulation from underlying factor deficiencies
when obtaining an abnormal CT [2].
Correlation of activated partial thromboplastin time performed on turbid
samples (n ¼ 539). The center line represents the regression line
between the STA and CA-1500 assay results, whereas the outer lines
represent the boundaries of the 95% prediction interval. Although
points outside the prediction interval can be considered outliers, these
points were included in the calculations as their effect on the final
results was negligible due to their locations and the large number of
patient samples. APTT, activated partial thromboplastin time.
Our results indicate that turbidity has no significant effect
on photo-optical detection as compared with mechanical
detection. We have shown equivalent results between
the two systems with 546 randomly selected samples with
visually observable interferences, including seven samples

Fig. 4 Fig. 6

Correlation of prothrombin time performed on turbid samples (n ¼ 546).
The center line represents the regression line between the STA and
CA-1500 assay results, whereas the outer lines represent the
boundaries of the 95% prediction interval. Although points outside the
prediction interval can be considered outliers, these points were
included in the calculations as their effect on the final results was
negligible due to their locations and the large number of patient
samples. PT, prothrombin time.
Correlation of Clauss fibrinogen performed on turbid samples
(n ¼ 539). The center line represents the regression line between the
STA and CA-1500 assay results, whereas the outer lines represent
the boundaries of the 95% prediction interval. Although points outside
the prediction interval can be considered outliers, these points were
included in the calculations as their effect on the final results was
negligible due to their locations and the large number of patient
samples. FIB, Clauss fibrinogen.

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that yielded ‘no clot’ on both systems. Of interest are four
nonturbid samples that yielded ‘no clot’ on the STA but
gave valid results on both the CA-1500 and tilt tube. We
noted that all four ‘no clot’ samples on STA were forming
tiny weak white clots by the tilt tube method, three of
which presented with ‘early reaction error’ along with an
APTT value on CA-1500. This indicated that the strength
of forming a mechanical clot on STA was so weak that the
formation of a firm clot was beyond the upper limit of the
CT setting (236 s for APTT). The fourth ‘no clot’ sample
was actually repeated on STA and revealed 35.5 s for
APTT, whereas it yielded 34.1 s on CA-1500 and 59.1 s
by the tilt tube method. The issue of sample integrity for
coagulation testing continues to be a growing concern in
clinical laboratory practice due to preanalytical error
caused by the blood collection personnel with varied
backgrounds and experience. Particularly, hemolysis
during the blood collection process must be identified
and those samples replaced with nonhemolyzed samples
when possible [19,20].
Unlike a mechanical detection system that provides only
an end point CT, the CA-1500 measures changes in
scattered light intensity at 660 nm for clotting assays and
records the light change process over the entire course of
clot formation [21]. During this time, detailed data analysis
generates the magnitude of sample turbidity (baseline
light intensity), degree of scattered light change and the
speed of reaction changes (early reaction identification).
This instrument possesses a sophisticated software algor-
ithm to record, monitor and flag reaction tracings and
determine the correct CT. By using the manufacturer’s
recommended procedures [15,21], an operator is able to
review the corresponding clot curve and analysis data,
providing complete sample information when needed.
For turbid samples, it is often advantageous to use a
longer wavelength (660 nm for CA-1500), which reduces
background absorbance, than shorter wavelengths [22], in
which transmitted light may be blocked by interfering
substances causing severe turbidity. Thus, a combination
of a longer wavelength and the use of sophisticated soft-
ware is a good solution for this purpose.
Regarding setting criteria to perform alternate procedures
(e.g. in the presence of significant hyperbilirubinemia)
[22], our study demonstrated equivalency between
photo-optical and mechanical detection methods. It is
therefore reasonable that one method may be used for the
other when considering repeat testing.
Conclusion
Our findings indicate that the rate at which both photo-
optical and mechanical detection of coagulation failed to
yield a measurable end point in routine patient samples
in a high-volume hospital setting was less than 1.2%.
Most notably, we also found that when testing subopti-
mal samples (i.e. hyperbilirubinemia, lipemia, etc.) the
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Clot detection for routine coagulation testing Bai et al. 575
photo-optical and mechanical detection methods are
statistically equivalent.
An advantage of photo-optical clot detection is the ability
to combine the review of the entire clot formation with
analysis by sophisticated software to aid in determining
the correct coagulation test parameters for patients with
unusual in-vitro clot reactions. Conversely, the limita-
tion with any mechanical detection system is that it only
provides the operator a single data point with no means of
further review. In the rare instance when a measurable
end point is not detected, it is important for laboratories
with either a photo-optical or mechanical system to
check the sample with an alternative method of clot
detection.
All data obtained during this study indicate that the
patient results obtained by the photo-optical detection
system are as reliable and statistically equivalent as those
obtained using the mechanical detection system.
Acknowledgement
This research was supported, in part, by a research grant
from Dade Behring Inc, Deerfield, Illinois, USA.
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