Suggestions for correct microbiological sampling of clinical specimen
Dr.Nancy Cornish (Nebraska Methodist Hospital & Children’s Hospital, Omaha, NE, USA)
(May 20, 2009 ASM Meeting)
(a) Microbiology Laboratory – Specimen Management
• Specimen Management in microbiology includes selection, collection, transport, storage, analysis and reporting
• If error occur at any point in this process (regardless of who may be responsible for the error) the result can be negative outcome for the patient, such as misdiagnosis, extended length of stay, and / or inappropriate therapy
(b) Microbiology Laboratory – Specimen Management
The specimen management impacts patient care and healthcare system in several important ways:
• It is the key to accurate diagnosis
• Directly affects patient care and outcome
• Influences therapeutic decisions
• Impacts hospital infection control
• Affects patient length of stay and overall hospital costs
• Plays major role in laboratory costs and efficiency.
(c) Need to Educate Clinicians
• Yes, they need to be educated because they do not already know this
• Medical and nursing schools do not routinely have formal courses focused on microbiology laboratory principles
• Medical student may get their laboratory education from peers
• Errors in understanding can multiply, details can be overlooked
(d) We need Teamwork
• Continuous education and partnership with clinicians who use microbiology services is necessary
• Teamwork also is needed:
-with other parts of he laboratory
-with nursing staff
-with infection control staff
-with public health authorities
• We have to follow national guidelines
• Everyone has the same goal: PATIENT SAFETY
(e) Risks in testing bad specimens
• If you work up an inadequate or inappropriate specimen, risks include:
-adverse outcome for patient
-potential for being considered fraud and abuse
-precedent for continue bad habits
• Remember that you have both direct and indirect(via clinicians) responsibility to the patient
-even if clinicians claims or demands to “accept full responsibility” you are still accountable
(f) Specimen Rejection
• Not long ago, easier to request another specimen: now “cost” of rejecting the specimen is much higher
• Regardless of the reason for a problem with the specimen, it is increasingly difficult to reject:
-often in outpatient setting, the patient and / or clinician is gone by the time the problem is identified -exacerbate by business relationship where “the customer is always right”.
(g) Specimen Rejection
• All decisions should be primarily (~exclusively) driven by consideration for patient care:
-can have overgrowth of non pathogens obscure test result (e.g.: quantitative urine culture)
-can have nonviable organisms, if transportation needs have not been met (e.g.: shaft of swab inhibit growth)
-avoid adverse implications for the patient due to FP/FN.
(h) Communications about Problem Specimens
• Busy clinicians and their support staff may focus on patient’s presentation and need for the test
• Explain the risk of error in terms of patient safety, not in terms of “red tape”:
-This is an opportunity for education
• You may have to contact more than one person to reach a decision
-Many act on behalf of someone else.
(i) Educate Clinicians Using Microbiology Services to:
• Collect specimens that are appropriate and representative for the stage of illness
• Collect prior to the administration of antibiotics / anti-virals
• Collect a sufficient volume / amount of specimen to ensure positive culture results
• Avoid contamination with normal bacterial population
(l) Educate Clinicians Using Microbiology Services to:
• Send specimen promptly and under appropriate storage conditions
• Label specimen container with patient identification information (not just the requisition), type of specimen, and source
• Indicate tentative diagnosis, if possible
• Consult with laboratory staff if there are any special considerations or problems.
