Specimen Collection and Source Mapping

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1 Specimen Collection and Source Mapping October 4, 2016 Steve Renfroe MT(ASCP) Consultant, Clinical Specialty

2 What is Your Culture? Does your urinalysis reflex to culture? Does Lab educate your Nursing staff and Physicians on culture collection from your hospital s policies? If not, why not? How often do you talk with your Lab techs? How do you find out about what s new? Do you (as an IP) have a champion in Lab for Best Practice?

3 Reflex Urine to Culture The reflex test is designed to assist the clinician with the diagnosis of urinary tract infection through initial screening of the urine sample by urine chemistry analysis (urinalysis) with defined result criteria triggering a urine culture. The theory behind this reflexive testing is to minimize the number of urine samples cultured, saving patient and laboratory expense as well as maintaining efficiency within the microbiology department. A more efficient workflow can be realized between the department where urinalysis is performed and the microbiology department where urine samples are cultured.

4 Reflex Urine to Culture PRO Faster culture set up & result turn-around-time Reduce chances of delay awaiting physician order Apply consistent criteria for culture set up based on UA triggers Buy in from medical staff for lab process CON There are few published data to support the practice of urinalysis with reflex to culture only if the urinalysis is positive (criteria vary among laboratories). 1 Reflex using only positive urinalysis criteria does not account for patient symptoms or asymptomatic presentation 1 Burd, E. & Kehl, K. (2011). Journal of Clinical Microbiology, S34-S38.

5 The Importance of this Process More than 70% of medical decisions, from diagnosis to therapy to prognosis are based on Lab results Martha J. Bale, MS, MT(ASCP) Vice President Division Manager, Infectious Disease ARUP Laboratories

6 Poor Collection Process & Contamination issues = Confusion for the Clinician Run a report for contam

7 Risks of a Poor Microbiology Specimen

8 Specimen Collection

9 General Collection Techniques Label specimens at the point of care with name, time of collection, type of specimen, site of collection, and diagnosis. Swabs are poor specimens, especially if wound biopsies or needle aspirates can be obtained. Exceptions: nasal, oral, and genital specimens If specimens can not be transported within 30 minutes, they should be refrigerated or frozen depending on the specimen and type of transport media.

10 Urine is sterile: Collection is difficult Collection: How is it really being collected? The Foley bag? Urinal or bedpan? Label collection method: Supra-pubic Aspirate In/Out or Straight Catheter Catheterized or clean catch Is it processed within 2 hours or refrigerated?

11 Blood Culture Collection Collection: Blood volume is important. 20 ml in a 2 bottle set is ideal. Label: Draw at least two blood culture sets. Two separate venipuncture draws. Results are influenced by effective skin decontamination at collection. Time, date and site of draw at the point of care. Transport: Do not refrigerate! Send directly to the lab.

12 Sputum Collection Collection: There is no reason to culture spit. Collect as early in the day as possible. Transport: Within two hours of collection.

13 Submit Specimens... Not Swabs Nancy Cornish MD

14 Wound Collection Collection: Tissues collected during surgery or aspirates through intact skin are preferred. Especially for anaerobic cultures Label: Specific labeling is crucial! Type of specimen (deep tissue, superficial tissue, boil, abscess, decubitus, surgical site, etc.) Anatomic location (arm, back, hip, etc.) Transport: Deliver to laboratory within 30 minutes. Do not refrigerate.

15 Stool Culture Collection Enteric pathogens and C. difficile toxin are unstable Collection: Do not contaminate with urine or toilet water. Specimens should be watery or loose and fit the clean, leak proof container (No Rock & Roll ). Do not perform routine stool culture on patients hospitalized >3 days. Label: Indicate whether the specimen is bloody. Transport: Deliver to laboratory within 30 minutes.

16 Source Mapping

17 Attention to Detail Quality of results is dependent upon the lab receiving the most information possible. Improving specimen collection leads to more accurate results for the patient. Improved source labeling leads to improved MedMined data.

18 Improved Surveillance Knowing the exact source is also important to infection surveillance. Different processes led to organisms in different specimens. urine vs. urine: catheter blood vs. blood: line Specimen information on the report can save time spent reviewing chart.

19 Overview - Source Mapping Raw sources come from your facility s laboratory information system (LIS). The description of source of the specimen is manually entered by nursing staff, laboratory staff or unit secretaries. In order to categorize this raw data, MedMined developed standard sources to which all client specimens are mapped.

20 Source Labeling... Getting It Right! Run a report for ICU : Urine Are they really all mid-stream clean catch as labeled?

21

22 Colony count Calibrated loops or pipettes are used to inoculate culture media for urine cultures. 1ul (0.001 ml) - detects col ct >1000 cfu/ml for routine, clean catch or foley urine. 10 ul (0.01 ml) - detects col ct cfu/ml for in/out caths or suprapubic. With a ml loop, each colony represents 1,000 CFU/ml. With a 0.01 ml loop, each colony represents 100 CFU/ml.

23 Source Labeling Affects NIM Eligibility Abscess v. Wound Abd Abscess >> Abscess Abd >> Wound Decubitus v. Wound Lt Leg Ulcer >> Decubitus[NNE] Leg >> Wound Derm v. Wound Skin scraping, arm >> Derm[NNE] Arm >> Wound

24 Infection Prevention Can Bridge The Gaps Nursing Lab Clinician Collection Analysis Diagnosis & Treatment TOGETHER you can change the culture!

25 Three Resources MedMined Services Laboratory Best Practice Guide and Quick Reference Specimen Collection Guide and MedMined Source Mapping Guide These guidelines are intended to be used in conjunction with your hospital s policies and products.

26 CDC Alert Candida auris Candida auris is an emerging multidrug-resistant (MDR) yeast that can cause invasive infections and is associated with high mortality Resistant to fluconazole, voriconazole, and amphotericin B Isolated from blood and wounds C. haemulonii isolates and other isolates from clinical specimens that cannot be identified beyond Candida spp. by conventional methods should be forwarded through state public health laboratories to CDC for further identification Use Standard and Contact Precautions

27 Things to consider Heighten awareness within hospital (esp. Micro and Pharmacy) Perform a quick lookback in MedMined. Run a report for all 3 organisms without defining any sensitivity criteria. Review for outlined drugs and find any resistance. Create a sentinel for future MDR Candida species and share with Micro and Pharmacy Inform Administration that the organism has been seen X times in the last number of years or not at all. Alert Public Health if necessary.

28 Learn more You can learn more about the article Global Emergence of Invasive Infections Caused by the Multidrug-Resistant Yeast Candida auris by following the link below:

29 Questions?

30 Thank you!

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