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Optimizing Specimen Management

Optimizing Specimen Management. Mike Miller, Ph.D., (D)ABMM. What is the Biggest Problem You Have with Specimen Management?. 1. Doctors who demand inappropriate testing 2. Pathologist(s) that won’t back me up 3. Personnel who don’t know how to collect 4. Poor quality specimens

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Optimizing Specimen Management

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  1. Optimizing Specimen Management Mike Miller, Ph.D., (D)ABMM

  2. What is the Biggest Problem You Have with Specimen Management? 1. Doctors who demand inappropriate testing 2. Pathologist(s) that won’t back me up 3. Personnel who don’t know how to collect 4. Poor quality specimens 5. Not sure of correct methods

  3. Impact of Specimen Management on Patient Care • Key to accurate laboratory diagnosis • Directly affects patient care and patient outcome • Influences therapeutic decisions • Impacts hospital infection control • Impacts patient length of stay, hospital costs, and laboratory costs • Influences laboratory efficiency

  4. Three Pitfalls in Specimen Management Preparing for the best!!

  5. The First Pitfall • Saying “yes” to everything • Accepting every specimen • Afraid to say “No” to doctors • Having no boundaries for technical issues • (This means that the doctor is in charge of your lab and your product)

  6. “Most laboratory work and the greatest cost will be associated with specimens of the least clinical value”. -Raymond Bartlett, M.D.

  7. “The number of species found in a clinical specimen is in some way indirectly proportional to the patient care value of the report”. -Ray Bartlett, M.D.

  8. Sites of Infection Where the Specimen is Likely to Become Contaminated During Collection • Middle ear ……………. External ear canal • Lower respiratory tract..Oropharynx • Nasal sinus…………….Nasopharynx • Bladder……………..… Urethra and perineum • Endometrium…………. Vagina • Superficial wounds…… Skin and membranes • Fistulae………………… GI tract Site Contamination Source

  9. The Second Pitfall • Saying “yes” to everything • Accepting every transport device • Afraid to say “no” to doctors • Having no boundaries for technical issues

  10. To Swab or Not to Swab! There once was a surgeon named Peters Who drained from an abscess three liters, But sent only a swab Labeled “Thing-a-ma-bob” For five cultures, six stains, and two titers. (Hint: Proper quantity and site, make cultures turn out right). -Jill E. Clarridge, III, Ph.D., ABMM Baylor College of Medicine Houston, TX

  11. Swabs for Specimen Collection • Bacteria, aerobic - cotton, dacron, or alginate is usually acceptable • Bacteria, anaerobe - tissue or aspirate is recommended. Resist placing swabs into Surgery. Use only anaerobe transport. • Chlamydia - Dacron or alginate but not cotton. Cytobrush is specimen of choice. No wooden shafts • Fungi - swabs not recommended • Viruses - cotton or dacron but not alginate. No wooden shafts or charcoal.

  12. Specimens to be Discouraged due to Questionable Microbial Information Superficial and Peridondal lesions, Decubiti, Varicose veins, Most burns, Superficial gangrenous lesions, Perirectal abscess Do not culture: Bowel content, vomitus, Foley catheter tips, discharge from colostomy, lochia, gastric aspirates of newborns

  13. Bad Omens for Good Results • Develop and document valid rejection criteria • Swabs to reject or resist: • Swabs of ears - labeled “ear” • Swabs from NP or nose - labeled “sinus” • Swabs of a body fluid - labeled “fluid” • Swabs for anaerobe culture - labeled “wound” • We need a specimen, not a swab of a specimen.

  14. The Third Pitfall • Saying “yes” to everything • Accepting every demand or request • Afraid to say “no” to doctors • Having no boundaries for technical issues • Blindly accepting every result as accurate, significant, and clinically relevant • Know the limits of our test methods • Know the significance of our results

  15. Are we too good? • Exhaustively good bacteriology produces irrelevant information which may mislead physicians into erroneous diagnosis and inappropriate therapy. • Ray Bartlett, M.D.

  16. Which report would you consider accurate enough for release? 1. “Proteus mirabilis” - ID at 92%. From urine. Kirby/Bauer results: Gent - S; Ceftaz - S, Imipenem - S; Tetra - S; Cipro - S; Nitrofurantoin - R 2. “Yersinia ruckeri” - ID at 96%. From diarrheal stool. 3. “Resembling Bacillus anthracis” - Gram pos rod, spore-former, nonmotile. From blood. Patient critical with pneumonia. A. 1 and 2 B. 2 and 3 C. 1 and 3 D. All E. Noneone

  17. Motivation to Say “NO” • Good laboratory practice - patients first! • Following the law - CLIA ‘88 • 493.1211 - The procedure manual must include requirements for specimen collection and processing, and criteria for rejection. • 493.1109 - Must indicate on the report any information regarding the condition and disposition of specimens that do not not meet the laboratory criteria for acceptability.

  18. Be Prepared to say “No”(professionally) • Specimen management manual - spend the time to write what you really need; then follow it! • QC policy - remember, specimens can be out of control. You should never report out-of-control results! • References - document your position! • Read-Read-Read! - budget time to keep up!

  19. Consultation Collaboration Communication Cooperation

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