1. CENTERS FOR DISEASE CONTROL AND PREVENTION Mike Miller, Ph.D., (D)ABMM

2. CENTERS FOR DISEASE CONTROL AND PREVENTION 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

3. CENTERS FOR DISEASE CONTROL AND PREVENTION 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. CENTERS FOR DISEASE CONTROL AND PREVENTION Three Pitfalls in Specimen Management Preparing for the best!!

5. CENTERS FOR DISEASE CONTROL AND PREVENTION 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. CENTERS FOR DISEASE CONTROL AND PREVENTION Most laboratory work and the greatest cost will be associated with specimens of the least clinical value. -Raymond Bartlett, M.D.

7. CENTERS FOR DISEASE CONTROL AND PREVENTION 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. CENTERS FOR DISEASE CONTROL AND PREVENTION Sites of Infection Where the Specimen is Likely to Become Contaminated During Collection Site Contamination Source 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

9. CENTERS FOR DISEASE CONTROL AND PREVENTION The Second Pitfall Saying yes to everything –Accepting every transport device –Afraid to say no to doctors –Having no boundaries for technical issues

10. CENTERS FOR DISEASE CONTROL AND PREVENTION 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 To Swab or Not to Swab!

11. CENTERS FOR DISEASE CONTROL AND PREVENTION 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. CENTERS FOR DISEASE CONTROL AND PREVENTION 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. CENTERS FOR DISEASE CONTROL AND PREVENTION 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. CENTERS FOR DISEASE CONTROL AND PREVENTION 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. CENTERS FOR DISEASE CONTROL AND PREVENTION 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. CENTERS FOR DISEASE CONTROL AND PREVENTION 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. CENTERS FOR DISEASE CONTROL AND PREVENTION 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. CENTERS FOR DISEASE CONTROL AND PREVENTION 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. CENTERS FOR DISEASE CONTROL AND PREVENTION