quality in the clinical microbiology laboratory 2

7/23/2019 Quality in the Clinical Microbiology Laboratory 2

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Antimicrobial disk susceptibility testing


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Quality in The ClinicalMicrobiology Laboratory

Dr.S.Hekmat

Reference Health Laboratory


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Total laboratory Quality Program

quality management(QM)

Continuous quality Improvement (CQI) or

Performance improvement (PI)

Quality Control (QC)

Quality Assurance (QA)


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Test Cycle

Preanalytical

)sampling , labelling , transport , storage , specimen clinical information

Analytical

)macroscopic evaluation , microscopy , culture , identification ,

interpretation , antibiogram, .. (

Post analytical

)Final report to pysician(


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Quality management ( QM)

QM is:

A process of loo!ing of "at is done

#o" it is doneIdentifying opportunities for improvement

Ma!ing te appropriate canges

Assessing te impact

QC and QA are integral and essential components

of QM.


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CQI and PI

CQI and PI "ent a step furter by see!ing to

improve patients care by placing te

empasis on not ma!ing mista!e on firstplace$ CQI and PI advocate continuous

training to guard against aving to correct

deficiencies


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QUALIT A!!U"A#C$ P"%&"AMM$

QA

% A quality assurance (QA) programme is concerned "it sampling,specifications and testing as "ell as "it organi&ation, documentation and release

procedures tat ensure tat te necessary and relevant steps ave been ta!en to ensure

satisfactory quality'

% e bacteriology and immunology laboratory is responsible for providing accurate and

relevant information tat is of use for clinical diagnosis of a patient or in support of a public

ealt activity' e accuracy and clinical value of te laboratory analysis of te clinical

specimen and microbial isolates are dependent upon a QA programme tat

% assesses the quality of the specimen,

% documents the validity of the test method,

% monitors the performance of test procedures, reagents, media, instruments and

personnel,

% and reviews test results for errors and clinical relevance

An effective QA programme is dependent on a continuous process of assessment and

improvement' It as t"o broad components

% Quality assurance * Internal quality control + Eternal quality

assessment


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Continue.

QA is te sum of activities to ensure tat test results are accurate ,reproducible and timely

#o"ever

e speed , te cost , and te usefulness or clinical relevance of te test

is important.

It must !e comprehensive,

concentrate on the most critical steps,

provide continuous monitoring of test procedures,

able to detect and correct errors as they occur.


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Internal 'uality control

% Internal quality control (IQ") is te set of procedures underta!en by

te staff of a laboratory for continuously and concurrently assessing

laboratory "or! and te emergent results, to decide "eter tey are

reliable enoug to be released' ese results may be required for a"ide variety of purposes$ e'g' support of clinical decision ma!ing or

epidemiological surveillance or researc' Internal quality control

procedures ave an immediate effect on te laboratory+s activities and

sould actually control as opposed to merely e-amining te

laboratory+s output'


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Internal Quality Control

IQC

Practical

.ealistic

/conomical


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QC program

e laboratory director is primarily

responsible for QC and QA programs'

#o"ever all laboratory personnel mustactively participate in bot program


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!ources o error that effect the reliability andreproducibility

Sampling , transport,storage, processing !pecimens

$nironmental actors !nade"uate space #orking:ventilation, temperature, e$cessive noise, unsafe #ork conditions,..

Personnel:

%ducation, training , e$perience, condition of employment

Laboratory materials

Quality or reagents, stains, chemicals, culture media, ,

Test method & some methods are more reliable

Substandard or poorly maintained instruments*$'uipments$+amination and reading Hurried Reading of results , failure to e$amine

sufficient number of microscopic fields,

"eporting


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Procedures

%#egins with proper la!oratory operations !ased on!%P!for:

Collection of specimen

.egisteration of specimen

Processing of specimen.

Care of equipment

Preparation and storage of culture media , stains , reagents and antisera

Antibiotic susceptibility tests

0toc! cultures0afety precautions

Personal ygiene

#andling and disposal of infected material

P t G id li


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Parameter Guidelines

Specimen collection and

transportation

Provide instructions for collection and transport

Establish criteria for acceptable specimens

Establish rejection criteria for unacceptable specimens

Personnel Use sufficient qualified personnel depending upon volume and complexities of work

Provide continuous technical education

Provide written performance standards

Evaluate annually

QC records Record all Q results on prescribed forms

Report all out!of!control observations to supervisor

"ote corrective actions on Q form

Review Q records monthly

Patient reports Report only to authori#ed personnel

"otify test requester of important values immediately

Provide normal ranges where appropriate

orrect errors in patient$s reports in timely fashion

Retain records for at least two years


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!nformation should be filled

Patient name

#ospital or laboratory number

1rdering pysician

2eter te patient receiving antimicrobial

terapy

0uspect agent or syndrome


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'ritten collection instruction

est selection criteria

Patients selection criteria

iming of specimen collection (e'g.,

3efore antimicrobial are administration(

1ptimal specimen collection site

Approved specimen collection metod0pecimen transport medium


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0pecimen transport time and temperature

0pecimen olding instructions if it cannot be

transported immediately (e'g' old at 4C for 54ours)

Availability of test (onsite or sent to reference

laboratory )

#ours test performed (daily or batc)

urn6around time

.esult reporting procedures


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Criteria for unacceptable specimens

7nlabeled or mislabeled specimens

7se of improper transport medium

/-cessive transport time

Improper temperature during transport or storage

Improper collection site for test request

0pecimen lea!age out of transport container


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(ersonnel

It is laboratory director8s responsibility to employ

sufficient "ualified personnelfor te volume and

comple-ity of te "or! performed.Document competency and training t#ice a year

Continuing education program sould be provided

All documentation sould maintained in personnelfile


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$+ternal 'uality assessment

% Eternal quality assessment (EQA), "ic "as earlier !no"n as

proficiency testing, refers to a system of ob9ectively assessing te

laboratory performance by an outside agency' e assessment is

retrospective and periodic in clinical microbiology unli!e industrial

microbiology suc as production of vaccines and immunobiologicals

"ic, as per te la"s of te land, require testing by an agency

independent of te manufacturer before teir release for use'

%$he main o!%ective of eternal quality assessment is to esta!lish

inter&la!oratory compara!ility' is "ill influence te reliability of

future testing' In contrast, te main ob9ective of internal quality control

is to ensure day6to6day consistency' #ence, both internal "uality control

and e$ternal "uality assessment are complementary in ensuring the

reliability of procedures, their results and finally the "uality of the

product


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"uality control of e"uipment

3iological safety cabinets

Autoclave

1ven

Incubator

.efrigerator2ater6 bat

Microscope


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Maintenance records sould be retained in te

laboratory for te life of instrument' 0pecific guidelines regardingperiodicity of testing for autoclaves, biological safety cabinets

,centrifuges ,incubators, microscope, refrigerators ,free&ers, "ater

bates , eat bloc!s and oter microbiology laboratory can be found in

reference boo!s


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Culture media

'rdering and storage of dehydrated media

1rder quantities for : monts or at most ; year.

e overall quantity sould be pac!ed in containers tat "illbe used up in ;65 monts.

2rite date of receipt on eac container

0tore in a dar! , cool, "ell ventilated place

2en a container is opened , "rite te date of opening on it


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%!torage o prepared media

% "e!s

%ubes "it loose caps 5 "ee!s

%containers "it scre" caps > monts

%Petri dises , sealed in plastic bags 4 "ee!s


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Commercially (repared Culture

)edia

e ?CC@0 subcommittee on media qualitycontrol collected data over several years regarding te

incidence of QC failure of commonly used microbiology

media 3ased on its finding te subcomm ittee publised a

list of media tat did not require retesting in te user8s

laboratory if purcased from a manufactures "o follo"

?CC@0 guidelines


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pH testing

Prepared media sould not be cec!ed routinely.

If it is prepared in ouse from basic ingrediente it sould be

allo"ed to cool before te p# tested.

0olid media "it a surface electrode or after macetration in

distilled "ater.

If p# differs B'5 units from te specification, ad9ust "itacid or al!ali or prepare a ne" batc.


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Sterility Check

A representative sample of eac media "ic blood

or teir components are added after autoclaving

sould be test for sterility$ >6D of any batc istested'

0terility is routinely cec!ed by incubating te

medium for 4E ours at te > C temperature '

More tan 5 colonies per plate if seen , discardte "ole batc..


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(erformance testing

2en medium dose need to quality controlled

because it "as prepared in ouse (in te

laboratory) or because it is comple-, several basicrules must be follo"ed:

All media must be tested before use

/ac medium must be tested "it organisms

e-pected to give positive reaction as "ell as "it

organism e-pected eiter not to gro" or produce a

negative reaction


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Performance testsfor differentcommonlyusedmediaare

Performedbydifferentmicroorganisms( stoc!culture )

#loodagar

:Performance test( emolysis and gro"t )s.(yogenes

s.(neumoniae

Medium #egatie *acitracin disc positie

s. pyogenes +one- %.faecalis blood agar

performed bydifferrentmicroorganisms (stoc!cultures )


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User,Prepared and #oncommercially prepared

Media

Q" forms for user&prepared media should contain:

e amount of prepared

e source of eac ingrediente lot number

e preparation date

e e-piration date (7sually ; mont for agar plate and : mont for tube

media)

0terli&ation metods:

All user prepared colures media also sould cec!ed for:


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Proper color


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!tain and "eagents

Containers of stains and reagents sould be labeledas to contents, concentration ,storagerequirements, date prepared (or received) date

placed in service ,e-piration date, source(commercial manufacture or user prepared) and lotnumber 'All stains and reagents sould be storedaccording manufacture8s recommendations and

tested "it positive and negative controls beforeuse.


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Antisera

e lot number, date received, condition

received ,and e-piration date must be

recorded for all sipments of antisera'Inaddition ,te antisera sould be dated "en

opened '?e" lots must be tested

concurrently "it previous lots, and testingmust include positive and negative controls.


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Use o !tock Cultures

o operate a quality control program, stoc! culture must be

maintained by all laboratories 'ey are available from

many sources.

"ommercial sources

"linical specimens

Proficiency testing

eference la!oratories'fficial "ulture "ollection (A$"")


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Preseration

ong *term

@yopili&ation

0torage at 6GBC 03 "it ; D Hlycerol

CA foreisseriaandstreptococci

Coo!ed6meat medium for anaerobes

hort&term

0A slants0tore in refrigerator

ransfer every 5 "ee!s.


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!tock strains or 'uality control suggusted by CL!I

%scherichia coli /0CC 12311

(seudomonas aeruginosa /0CC 14526

Staphylococcus aureus /0CC 12316Streptococcus pneumoniae /0CC 73893

%nterococcus faecalis /0CC 13191

Haemophilus influenae /0CC 73174

/0CC 4::86 (neumoniae ;lebsiella


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Antimicrobial !usceptibility Testing

( A$ )

M/#1


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"eagents or the -isk -iusion Test

1-0election of Antimicrobial


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Mueller .inton Agar Medium

Preparation of Mueller #inton Agar

Moisture

P#/ffects of ymidine or ymine

/ffects of Jariation in


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Turbidity !tandard

0.5c-arland standard

)0.5ml of B'B4E molKml 3aCl5 added to

99.5ml of B';E molK@ #5014(;D vKv)density in ./0 nm 1 2324 & 235

6eep in 7&. ml aliquots in screw captu!es in dar8 , room temperature

eplace or verify density mont


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BLKB:K; A0 45


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BLKB:K; A0 4>


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Common sources o error

Inhi!itory su!stance thymine and thymidine:%nterococcus faecalis /0CC 13191 or 66958 tested by S


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!almonella and !higella

:-ecal isolates

Ampicilin , a quinolone , 0

Etraintestinal isolates of!almonella;

In addition clorampenicol and a tird

generation cepalosporin sould be tested

and reported.


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?ibrio cholerae

I"is te best metod:

3rot or agar dilution metod

Anti!iotic agents:

Ampicillin

etracycline0

Clorampenicol


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/ntibiotic susceptibility of #eisseriagonorrhoeae

edium : ;" agar

Inoculum < =irect colony suspension

Incu!ation < >0 " , 0? "'/ , /2&/7h


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(atient Report

e laboratory sould establised asystem for

supervisory of all laboratory reports.is revie"

sould involve checking the specimens #orkuptoverify tat te correct conclusion "ere dra"n and

no clerical errors "ere made in reporting results'

.eports sould be given only given only

autori&ed by la" to receive tem.


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Clinician sould be notified about panic

valuesimmediately' Panic values are

potential6treatening results, for e-amplepositive Hram stain for C0F or a positive

blood culture' All patients records sould be

maintained for least 5 years.

quality in the clinical microbiology laboratory 2

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