*NCCT is approved as a provider of continuing education programs in the clinical laboratory sciences by the ASCLS P.A.C.E. Program, provider #122.

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1 COURSE DESCRIPTION Have you ever wondered why the blood that a phlebotomist collects in a tube will form a clot unless certain chemicals are added to the tube in advance to prevent it? Have you ever wondered why blood clots faster in tubes with clot activators, or how those clot activators work? Have you ever wondered how the human body stops itself from bleeding when cut? Have you ever wondered whether the mechanism the body uses to stop bleeding is anything like the mechanism that causes clotting in test tubes? Have you ever wondered why laboratory tests must use clotted blood for some tests, but cannot use it for others? If you have ever wondered any of these things, you will find these answers and more within this continuing education module on coagulation. Beware, however. This is not for the faint of heart! If you are ready for the challenge, read on *Valid for P.A.C.E. credit through 12/31/2019* * ASCLS P.A.C.E. is an approved continuing education agency by the California Department of Health Laboratory Field Services, Accrediting Agency #0001. *NCCT is approved as a provider of continuing education programs in the clinical laboratory sciences by the ASCLS P.A.C.E. Program, provider #122. Rev 11.0 January 2018 COPYRIGHT 2018 National Center for Competency Testing Reproduction or translation of any part of this work beyond that permitted by Sections 107 or 108 of the 1976 United States Copyright Act without the permission of the copyright owner is unlawful. No part of this work may be reproduced or used in any form or by any means-graphic, electronic, or mechanical, including photocopying, recording, taping, or information storage and retrieval systems without written permission of the publisher. 1

2 COURSE TITLE: Coagulation Demystified Author: Kay C. Bertrand, MA Ed., MT(ASCP) Vice President, Exam Development National Center for Competency Testing Number of Clock Hours Credit: 1.0 Course # Level of Instruction: Advanced P.A.C.E. Approved: _X_ Yes _ No OBJECTIVES Upon completion of this continuing education course, the professional should be able to: 1. Define hemostasis in the human body. 2. Recognize the cells and coagulation factors involved in coagulation. 3. Describe the intrinsic, extrinsic, and common coagulation pathways. 4. Differentiate processes involved in the primary and secondary stages of hemostasis. 5. Describe what happens in the first hour after a whole blood sample is collected in an evacuated tube without an anticoagulant. 6. Describe the purpose of a clot activator in a blood collection tube. 7. Describe the purpose of a serum separator in a blood collection tube. 8. Differentiate between whole blood, serum and plasma collections. 9. Identify additives in common evacuated blood collection tubes by stopper color. 10. Recognize common medical laboratory tests that involve coagulation. 11. Recognize common tests for monitoring patients on anticoagulant therapy. 12. Recognize the importance of proper collection and handling of blood samples to prevent errors related to coagulation and anticoagulation. Disclaimer The writers for NCCT continuing education courses attempt to provide factual information based on literature review and current professional practice. However, NCCT does not guarantee that the information contained in the continuing education courses is free from all errors and omissions. 2

3 COAGULATION BASICS Coagulation occurs both inside and outside the human body, and can be a good thing or a bad thing. Inside the body, it is a good thing as a healing mechanism for the body to repair an injured blood vessel, but unwanted when a blood clot forms on its own. Blood clots inside the body may move through the circulatory system to other parts of the body, causing serious medical problems or even death. In blood sample collection tubes for laboratory testing, the presence or absence of coagulation is test dependent. Some laboratory tests may need to access or analyze products that are available in either the presence or absence of a clot. The simplest way to begin a discussion of coagulation is to define the players in the coagulation process inside the body. Perhaps the most prominent player is the platelet (PLT), one of three formed elements in the bloodstream. The other two players are the red blood cells (RBCs) and white blood cells (WBCs). Platelets are smaller and more irregularly shaped than either red blood cells or white blood cells are, and are activated when the body recognizes that a blood vessel has been damaged. When there is a break in a blood vessel, the body goes to work to stop the bleeding in a process known as hemostasis. The word hemostasis is derived from hemo (meaning blood) and stasis (meaning stoppage). In the human body, coagulation is a crucial part of hemostasis. In vivo coagulation occurs inside the human body and in vitro coagulation occurs outside it. Hemostasis is also referred to as the coagulation process. INSIDE THE BODY: STAGES OF HEMOSTASIS When a blood vessel is injured, blood may leak out causing anything from simple bruising to more serious bleeds. With any such injury, the body goes to work to repair the damage through the process of hemostasis. There are two phases: (1) primary and (2) secondary. PRIMARY HEMOSTASIS In the normal population, coagulation begins as soon as a blood vessel has been damaged. This damage might be caused by a bruise, wound, or anything else that causes bleeding. After a vessel injury, the primary focus of the body is to stop the leakage of blood. Intact skin helps with the containment as vasoconstriction and platelet plug formation begin inside the vessel. Vasoconstriction Vasoconstriction means literally blood vessel tightening. This decreases the flow of blood at the injury site. Injured/ exposed tissues release factors (coagulation factor III) that cause changes to platelets and activate the plasma protein fibrinogen (CF 1). This is called platelet activation. 3

4 Platelet Plug Formation Platelet activation allows platelets to (1) stick to each other (platelet aggregation) and (2) adhere to the injured area (platelet adhesion). This combination of platelets and fibrinogen result in the formation of a platelet plug at the site of the vessel injury, completing the process of primary hemostasis. The platelet plug is one of the first defenses a body has to stop bleeding. Patients must have an adequate number of functional platelets to form a platelet plug. If this plug is sufficient to stop bleeding, the body has done its job. Laboratory tests such as bleeding times or platelet function assays can be used to determine how quickly and effectively a patient s body can form platelet plugs. SECONDARY HEMOSTASIS If injury to a vessel requires more than just a simple platelet plug to stop the bleeding, a secondary process of hemostasis begins. The goal of this stage of hemostasis is the formation of a fibrin clot. Fibrin clots are formed by a network mesh of fibrin strains that combine with red blood cells and platelets to add strength and durability to the repair. Fibrin Clot Formation To form the fibrin clot, specific coagulation factors are required. These factors activate one another in a waterfall or cascade effect. These coagulation factors have been named and numbered using Roman numerals, and sit in readiness for activation by the clotting process. Once one factor in the cascade is activated, it activates the next factor in a specific sequence, and this continues until the fibrin clot is formed. The coagulation cascade can be initiated in two ways: (1) the extrinsic pathway (i.e. tissue factor pathway) and (2) the intrinsic pathway (i.e. contact activation pathway). These two paths come together in a combined common pathway to ultimately form a fibrin clot. A general discussion of all three pathways follows. Readers may want to refer to Figures (1) for a list of the factors by name and number, and (2) for a visual representation of the actual paths of activation. The Tissue Factor Pathway (i.e. Extrinsic Pathway) The primary path for the initiation of blood coagulation is the tissue factor pathway. It begins when thromboplastin is released from injured tissue. The main purpose of this pathway is to generate thrombin immediately. Factor VII leaves the circulation and comes into contact with the tissue factor, forming an activated complex of the two. This is the first step in the extrinsic coagulation pathway, which is something of a chain reaction. From that point on, each step activates something necessary for the next step. The tissue damage activates coagulation factor VII, which activates X. Activated X, in the presence of calcium ++ ions, platelets, and coagulation factor V will convert prothrombin (factor II) to thrombin. Thrombin activates factor XIII and converts fibrinogen to fibrin, i.e. the actual fibrin clot. In the presence of activated factor XIII, the fibrin clot is stabilized. See Figure (2) for detail. 4

5 The Intrinsic Pathway The intrinsic pathway appears to play a bigger role in inflammation than it does in clot formation. This path involves coagulation factors that circulate inside the bloodstream. Refer again to Figure (2). This path begins with HMWK, prekallikrein, and coagulation factor XII forming a complex with collagen (tissue). Prekallikrein is converted to kallikrein. Factor XII is activated, which then activates XI, IX, and X (with VIIIa) to begin the common pathway. The Common Pathway Activated coagulation factor X, along with several cofactors, facilitates the conversion of fibrinogen (coagulation factor I) to fibrin, the foundation of the platelet plug. Other factors then stabilize it. For inquiring minds, a list of the major coagulation factors and their names is included in Figure 1 and a diagram of the cascade is included in Figure 2. Figure 1. Major Coagulation Factors Coagulation Factor Activated Name by Roman Numeral Designation I Ia Fibrinogen II IIa Prothrombin III IIIa Tissue factor / Co-factor of VIIa IV IVa Calcium ++ V Va Proaccelerin / Labile Factor VI VIa No name assigned VII VIIa Proconvertin / Stable Factor VIII VIIIa Anti-hemophilic Factor A IX IXa Anti-hemophilic Factor B or Christmas Factor X Xa Stuart-Prower Factor XI XIa Plasma Thromboplastin Antecedent XII XIIa Hageman Factor XIII XIIIa Fibrin-Stabilizing Factor 5

6 Figure 2. The Coagulation Cascade and Pathways Based on information in Pallister CJ and Watson MS (2010) Haematology, United Kingdom: Scion Publishing, pp ISBN: This file is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license and is free for use if attribution is given. Fibrinolysis The last step in secondary hemostasis is fibrinolysis, which literally means dissolving or breaking apart the fibrin clot. During the clotting process, plasminogen is converted to plasmin. Plasmin can break apart the fibrin clot, forming byproducts called fibrin degradation products (FDPs). The D-dimer is one of those products, and is a laboratory test commonly ordered to determine whether clot formation (e.g., deep vein thrombosis or pulmonary embolism) has occurred. In vivo clotting can be very serious, so these tests are crucial for patient diagnosis and treatment. Related Trivia For inquiring minds who want to know, Figure (3) provides a list of additional coagulation related substances. These substances may help clots to form or dissolve. In this continuing education course, participants will not be expected to answer detailed questions about these factors, but some familiarity may be of value on the job. For example, healthcare professionals who work in stroke centers or emergency rooms may have heard of tpa administered to patients with strokes, and it is part of this list. Professionals performing venipuncture may have been asked to collect blood samples 6

7 for factor assays by name. This list will give readers a better idea of the full complexity of coagulation processes, even though this course is only an introduction. Figure 3. Coagulation Related Substances Coagulations Related Substances Function von Willebrand Factor Binds to VIII, helps platelet adhesion Prekallikrein (Fletcher Factor) Activates XII High Molecular Weight Kininogen Fitzgerald Factor: supports activation of XI, XII, and prekallikrein Fibronectin Mediates cell adhesion Antithrombin III Inhibits IIa, cofactor for heparin Protein C Inactivates Va and VIIIa Protein S Cofactor for activated C Protein Z Mediates thrombin adhesion, and more ZPI Degrades Factor X Plasminogen Converts to plasmin Alpha 2-antiplasmin Inhibits plasmin tpa Tissue plasminogen activator Urokinase Activates plasminogen PAI 1 Plasminogen activator inhibitor -1 PAI 2 Plasminogen activator inhibitor -2 Cancer Procoagulant Pathological factor X activator COAGULATION TESTS There are numerous tests used to assess the function of the coagulation system. Some of the most common are listed below. The Prothrombin Time or PT test evaluates the extrinsic coagulation pathway. This test is valuable for monitoring patients on Coumadin (warfarin) anticoagulant therapy. Results are often reported as an INR (international normalized ratio). The INR ratio is used for reporting to standardize results, and is essentially an adjusted ratio of a patient s PT to a control PT (i.e. a normal control). The activated Partial Thromboplastin Time (aptt) test is used to monitor both the intrinsic and common coagulation pathways. It is valuable for monitoring patients on heparin therapy. Platelet counts and platelet function assays/ tests monitor platelet availability and effectiveness. Assays for specific coagulation factors can determine whether specific factor deficiencies exist. The presence of D-dimers is used to rule the formation of clots in or out in treatment a patient. 7

8 The table below provides expected laboratory results in some common platelet and coagulation conditions or disorders. Figure 4. Laboratory Results in Common Platelet and Coagulation Disorders Condition / Disorder Prothrombin Time Activated Partial Thromboplasti n Time Platelet Count Bleeding Time or Platelet Function Assay Warfarin A N N N (Coumadin ) therapy Heparin therapy N A N N Vitamin K deficiency A N N N DIC (disseminated A A A A intravascular coagulation) Hemophilia N A N N von Willebrand N A A A disease Aspirin N N N A Thrombocytopenia N N A A Key A = abnormal test result N = normal test result Platelet disorders Platelet (thrombocyte) conditions may be inherited or acquired. Most of the inherited conditions are rare. Von Willebrand disease is an example, and is relatively common in its milder forms; patients are predisposed to bleeding issues. Patients may have too few platelets for a variety of reasons, which can also result in bleeding programs. They may produce too few (e.g., bone marrow disorders), they may be destroyed by the immune system (e.g., immune thrombocytopenic purpura or ITP), or they may be consumed (e.g., DIC). These can be very serious. IN VITRO COAGULATION: THE BLOOD COLLECTION TUBE When the laboratory decides the type of specimen it will need for any analysis, it will take into consideration both the analyte (i.e. substance being tested) and the method of analysis. Laboratory analyses differ from lab to lab. The collection requirements in one laboratory may be different in another laboratory, even if the test name/substance/analyte is the same as a different method of analysis is used. Why is it important to know about laboratory method variances? It is crucial that individuals collecting blood samples understand that there are literally hundreds, if not thousands, of laboratory tests with almost as many different methods for doing them. It is crucial to collect the correct sample for the laboratory performing the analysis. Lab testing follows the GIGO rule used in computer programming-garbage In, Garbage Out. If the sample is collected incorrectly, the results are worthless. 8

9 Some laboratory tests require serum or plasma for testing. Other laboratory tests require a whole blood sample, meaning that the sample should mimic blood in the state it exists in the patient s blood stream. There are also times when the laboratory will need cells or blood smears for testing as well. The presence or absence of coagulation affects the quality of all these samples. As an example, the specimen needed for a Complete Blood Count (CBC) requires a specimen that is anticoagulated with the additive EDTA. The blood specimen is thoroughly mixed before testing to assure the blood in the tube is as close as possible to the blood in the patient. If a clotted specimen were collected for a CBC, it would be unacceptable because it is not the same as the blood in the patient. The patient would need another venipuncture to collect an EDTA-anticoagulated specimen to assure the test results reflect the status of the patient. NO ADDITIVES Blood that is collected in evacuated tubes with no additives will typically clot (coagulate; i.e., form a fibrin clot) within 30 to 60 minutes. This is the same fibrin clot that forms inside the body when clotting occurs, although the cascade will be initiated via the intrinsic pathway since there is no release of a tissue factor in the tube. When the blood is collected, it looks as it does in the circulation. As the blood sits, the cellular components settle into the fibrin clot that forms, leaving serum in the top of the tube. To fully separate the cells from the serum, samples are usually spun down in a centrifuge at a high rate of rotation. It is important that tubes containing blood for serum testing be allowed to fully clot. Centrifugation of tubes before 60 minutes may result in an incomplete clot that contains strands of fibrin. Fibrin strands make the specimen difficult to work with, and it may cause problems in the testing. Serum is like plasma, but without the fibrinogen as the fibrinogen was converted to fibrin when the blood clot was formed. Serum is typically a clear fluid with a pale straw (i.e. yellow) color. Figure 5 shows a centrifuged red stoppered tube containing a serum separator gel. Figure 5: Centrifuged Blood Specimen with no Anticoagulant 9

10 CLOT ACTIVATORS AND SEPARATORS Serum samples may also be collected in evacuated blood collection tubes that have clot activators and/or clot separators (gel) in them. These typically reduce the time needed for clotting to 30 minutes and improve the quality of cell/serum separation. However, most manufacturers recommend waiting at least 30 minutes before centrifuging the tubes to obtain a serum sample. Thrombin Separator Gel Thrombin is added to gray/yellow topped tubes to produce a serum sample in less than 5 minutes. Inert (non-reacting) polymer gel that during centrifugation moves between the clot and serum providing a barrier. The gel prevents substances (such as potassium) that are released from the red blood cells from entering the serum resulting in altered test results. Figure 6: Evacuated Tubes used for Serum Collection Tubes with Conventional Stopper Tubes with Closures Additive Gray Gray* Sodium fluoride (invert 8 X after filling) None applicable Royal blue* No additives (no inversions required after filling) Red Red Two tubes 10 Silicone coated (glass tubes) (no inversions required) Clot activator & silicone coated (plastic tubes) (invert 5 X after filling) Red/Gray Gold Clot activator & separator gel (invert 5 X after filling) Red/Light Gray Clear over red No additives (no inversions required after filling) Yellow/Gray Orange Thrombin-based clot activator (invert 8 X after filling) *These tubes also come with anticoagulant additives. The label must be checked to identify if they are tubes that produce serum or tubes that produce plasma. COMMON ADDITIVES THAT PRODUCE PLASMA AND CELLS Many laboratory tests are performed on plasma or whole blood. To obtain specimens for these tests, blood is collected into evacuated tubes containing an anticoagulant. There are several types of anticoagulants, and each type disrupts the coagulation cascade in a specific manner to so the blood specimen does not form a clot. The type of anticoagulant used depends on the laboratory test being performed. The anticoagulant must not interfere with the analytic process and result in erroneous test results. Extensive scientific research has been performed to identify the correct anticoagulant to use for specific laboratory tests. The anticoagulant in the tube must be thoroughly but gently mixed with the blood when the tube is filled. If the blood specimen does not come into contact with the anticoagulant, small blood clots may form in the tube making the specimen unsuitable for testing.

11 Whole blood specimens can be analyzed after mixing the specimen. If plasma is needed for the laboratory test, the specimen must be centrifuged. The following graphic shows the composition of a centrifuged anticoagulated blood specimen. Figure 7: Centrifuged Anticoagulated Blood Specimen Following is a list of anticoagulants that prevent clotting, resulting in a sample with cells and plasma. The corresponding tube types, by stopper and closure color, are included. Figure 8: Blood Collection Tubes with Anticoagulants Invert 8 X after filling unless otherwise indicated. Tubes with Conventional Tubes with Closures Anticoagulant Stopper Light blue (invert 3-4 X after filling) Light blue (invert 3-4 X after Sodium citrate - 2 sizes filling) Gray Gray Potassium oxalate/sodium fluoride Gray Gray Sodium fluoride/sodium EDTA Green Green Sodium heparin or lithium heparin Green and gray Light green Lithium heparin and gel for plasma separation Lavender Lavender Potassium EDTA Not applicable Clear over light blue stopper Sodium citrate (invert 3-4 X after filling) Not applicable Royal blue Potassium EDTA Not applicable Tan Potassium EDTA Not applicable White Sodium EDTA and gel for plasma separation Pink Pink Potassium EDTA Yellow Not applicable Acid citrate dextrose (ACD) Solution B Yellow Not applicable Sodium polyanethol sulfonate (SPS) Yellow Not applicable Acid citrate dextrose (ACD) - Solution A 11

12 When blood is collected into an evacuated tube containing an anticoagulant or additive, the tube should be gently inverted to assure thorough mixing of the substances. The number of inversions varies depending on the type of additive or anticoagulant, as identified in the tables. If the blood does not thoroughly come into contact with the anticoagulant or additive, the specimen will be unacceptable for laboratory testing as the patient test results will be inaccurate. SUMMARY This continuing education module is designed to help the reader fully appreciate the importance of the many variables that may affect hemostasis in the body, coagulation and anticoagulation of blood samples, and related testing in the medical laboratory. Proper sample collection insures that the cells, serum, plasma, or whole blood needed for laboratory tests is collected and processed accurately to insure that patient results provide correct information for their diagnosis and treatment. It is not expected that readers should or will remember all the detail, but knowing the complexity and delicate balances involved in hemostasis and coagulation may provide healthcare professionals with a new respect for the related specimen collection and handling processes. REFERENCES Garza, Diana and Becan-McBride, Kathleen. Phlebotomy Handbook: Blood Specimen Collection from Basis to Advanced. 8 th Edition. Pearson Education, Inc Kalanick, Kathryn. Phlebotomy Technician Specialist. 2 nd Edition. Delmar Learning McCall, Ruth and Tankersly, Cathee. Phlebotomy Essentials. 5th Ed. Lippincott, Williams, and Wilkins Accessed 11/2/2012: Accessed 11/3/2012: Accessed 9/22/2015: QUESTIONS Coagulation Demystified # Directions: Answer sheets: Read the instructions to assure you correctly complete the answer sheets. Online: Log in to your User Account on the NCCT website o NOTE: If the online test questions differ from the course test that follows the reading material, the CE course you are using is outdated or the question has been revised since you downloaded it. The online question is the most current and it should be answered accordingly. Select the response that best completes each sentence or answers each question from the information presented in the course. 12

13 If you are having difficulty answering a question, go to and select Forms/Documents. Then select CE Updates and Revisions to see if course content and/or a test questions have been revised. If you do not have access to the internet, call Customer Service at Which of these definitions is closest to the meaning of the term hemostasis? a. In vitro coagulation b. In vivo coagulation c. Blood stoppage d. Blood clotting 2. Which of the following are the cellular components of blood that are the most prominent players that move into action upon the body s recognition of an injury to a blood vessel? a. Red blood cells b. Platelets c. White blood cells d. Epithelial 3. Which of these processes occur during primary hemostasis? a. Vasoconstriction and platelet plug formation b. Platelet plug and fibrin clot formation c. Fibrin clot formation and fibrinolysis d. Fibrinolysis and vasoconstriction 4. Which of these processes occur during secondary hemostasis? a. Vasoconstriction and platelet plug formation b. Platelet plug and fibrin clot formation c. Fibrin clot formation and fibrinolysis d. Fibrinolysis and vasoconstriction 5. Which hemostasis process causes the tightening of blood vessels to occur? a. Vasoconstriction b. Platelet plug formation c. Fibrin clot formation d. Fibrinolysis 6. Which hemostasis process needs platelet aggregation and adhesion to occur? a. Vasoconstriction b. Platelet plug formation c. Fibrin clot formation d. Fibrinolysis 13

14 7. Which hemostasis process needs a majority of the coagulation factors to take place? a. Vasoconstriction b. Platelet plug formation c. Fibrin clot formation d. Fibrinolysis 8. Which of the coagulation pathways is initiated when thromboplastin is released from injured tissue in a blood vessel? a. Intrinsic b. Extrinsic c. Common d. Fibrinolytic 9. Which of the activated coagulation factors facilitates the conversion of fibrinogen to fibrin in the common pathway? a. VI b. XII c. X d. IX 10. Which of these laboratory tests can help the primary care provider to know when a clot was present in a patient? a. Platelet count b. Prothrombin time c. Activated partial thromboplastin time d. D-dimer 11. Once blood is collected into an evacuated glass tube with no additives, how long will it take for clotting to occur? a. 5 minutes b minutes c minutes d. 1-2 hours 12. What is the purpose of a clot activator in a blood collection tube? a. It keeps the blood from clotting b. It helps the blood clot faster c. It activates fibrinolysis d. It adds platelets to the blood 14

15 13. What is the purpose of a serum separator in a blood collection tube? a. It separates RBC, WBC, and platelet layers b. It separates the full fibrin clot from the serum c. It separates the serum from the plasma d. It separates platelets from the other formed elements 14. Which of these evacuated blood collection tubes uses EDTA as an additive? a. Red stoppered tubes b. Light blue stoppered tubes c. Lavender stoppered tubes d. Yellow stoppered tubes 15. Which of these evacuated blood collection tubes with conventional stoppers has no additive? a. Red b. Light blue c. Red/light gray d. Green 16. Which of these common laboratory tests is used as a primary monitor for patients on warfarin therapy? a. Platelet count b. PT c. aptt d. CBC 17. Which of these coagulation conditions (see Figure 4, page 8) will cause the most coagulation tests to be abnormal? a. Hemophilia b. von Willebrand disease c. Coumadin therapy d. Disseminated intravascular coagulation 18. What will happen if a red stoppered blood collection tube is drawn for a complete blood count? a. The counts will be artificially low b. The counts will be artificially high c. The lab will just use the serum d. The sample will have to be recollected 15

16 19. What may happen if blood collected without an additive is centrifuged before it has completely clotted? a. The cells may disintegrate, causing errors in testing b. Fibrin strands in the serum may interfere with testing c. The clot may dissolve, with cells released into serum d. The clot may never form 20. When blood is collected with an anticoagulant in the blood collection tube, what should happen immediately after collection? a. Blood should be gently inverted to mix them b. Blood should be allowed to sit without disturbance c. Blood should be shaken to ensure distribution of additive d. Blood should be stirred with wooden sticks for best results *end of test* 16

17 NCCT 7007 College Boulevard Suite 385 Overland Park, KS P.A.C.E. Course Evaluation Directions: Please let us know whether this CE Course met your expectations by answering the following questions. Your feedback helps us to make our products better for you! Course Title: Coagulation Demystified Course Number: OBJECTIVES Yes No Yes No 1. Did you meet the objectives while reading this CE course? 2. Did the test measure what you learned? COURSE CONTENT Yes No Yes No Yes No 3. Were you satisfied with this course? 4. Was the CE course organized and useful for learning? 5. Was this CE course written at the right level for the practicing professional? VALUE Yes No Yes No Maybe 6. Did you learn anything new? 7. Did you learn anything you might use at work? What can NCCT do to make the CE courses better for you? What would you like to learn about in the future? Please list specific topics! *Please include this evaluation with your answer sheet.* 17