Optimizing Specimen Management

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Optimizing Specimen Management
Mike Miller, Ph.D., (D)ABMM
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What is the Biggest Problem You Have with
Specimen Management?
1. Doctors who demand inappropriate testing 2.
Pathologist(s) that wont back me up 3.
Personnel who dont know how to collect 4. Poor
quality specimens 5. Not sure of correct methods
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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

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Three Pitfalls in Specimen Management

• Preparing for the best!!

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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)

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Most laboratory work and the greatest cost will
be associated with specimens of the least
clinical value. -Raymond Bartlett, M.D.
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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.
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Sites of Infection Where the Specimen is Likely
to Become Contaminated During Collection
Site

• 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

Contamination Source







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The Second Pitfall

• Saying yes to everything
• Accepting every transport device
• Afraid to say no to doctors
• Having no boundaries for technical issues

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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
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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.

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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
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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.

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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

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Are we too good?

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

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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
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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.

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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!

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Consultation
Collaboration
Communication
Cooperation