Medical Microbiology

Topic: Processes being carried out in the Diagnostic Bacteriology laboratory

I am attached to the Department of Diagnostic Bacteriology for the next 20 weeks. But as this department consists of several labs, such as the anaerobic lab and investigation lab, I will be shuffled around so that I can try most of the tests or tasks being carried out in the different labs. The purpose of this department is to detect the presence of bacteria in the specimens and then identify the bacteria present.

Currently for the first 5 weeks, I am attached to the central processing lab. This lab is in charged of just detecting if there is any bacteria present in the patients’ specimens. So, blood, urine, stool, and other specimens from the body will be received. We are then supposed to process or prepare the specimens received for further testing. Then from here, the specimens will then be sent out to other labs to identify what kind of bacteria is present.

In the central processing lab, it is further divided into 7 parts.

1. Blood
2. Diagnostic stool (DS)
3. Diagnostic urine (DU)
4. Diagnostic respiratory (DR)
5. Diagnostic miscellaneous (DM)
6. MRSA screening
7. Microscopic examination (ME)

So I am now processing specimens for DM. The principle of DM is that any microorganism from a sterile site is important. Standard pathogens that grow from sites with normal commensal bacterial are also significant. This station is in charged of processing specimens for gram-staining and culture for aerobic bacteria.

Specimens received in DM are normally from the eye (e.g optisol media etc.), extremities (e.g toe or finger etc.), different parts of the body (e.g neck or back etc.) or bodily fluids (e.g abdomen ascites or liver abscess etc.).

The specimens can come in different forms and for culture for aerobic bacteria, different form of specimens would require different type of processing.

Forms of specimens	Processing required
Fluid Excluding: Bile	BP (CO2) SS + MAC + CM + ANA BP + MAC + CM
Tissue	BP (CO2) SS + MAC + CM + ANA
Wound ; Swab ; Pus	BP + MAC + CM
Eye Excluding: Contact lens case / solution Optisol media	BP (CO2) SS BP (CO2) SS + CM + MAC BP (CO2) SS + CM
Genital * Male urethra or any discharge from the urethra Excluding: High vaginal swab ; low vaginal swab (HVS / LVS)	BP + MAC BP + MAC + GC BP + LIM broth
Catherer	BP

Table 1

Abbreviations:

BP = TSA blood agar plates

SS = Staphylococcus aerus

MAC = MacConkey agar

CM = cooked meat

ANA = CDC anaerobic agar plates

GC = GC plates

Procedures

For all specimens, before starting anything, the following steps must be done.

1. Check the correct test is ticked on the request form.

2. Check that the patient’s name on the specimen tallies with the name on the request form.

3. Check that the specimen received is the same as the specimen stated on the request forms. (e.g If ‘tissue from left toe’ is written on the request form, ‘tissue from left toe’ must also be written on the specimen bottle)

4. Paste a number onto the request form.

i) For gram staining

a) If the specimen is watery or soft:

1. Paste a number on to a slide.

2. Flip the slide and draw a circle to indicate where the specimen is.

3. Put the specimen and slide into BSC (biological safety cabinet).

4. Wipe the side of slide without the circle with alcohol swab.

5. Place the slide onto a heater to dry the slide.

6. Use a dropper and place a drop of the specimen onto the slide.

7. Use a disposal inoculating loop to spread the specimen around.

8. Place the slide onto the heater to dry the slide.

b) If the specimen is dry:

1. Paste a number on to a slide.

2. Flip the slide and draw a circle to indicate where the specimen is.

3. Put the specimen and slide into BSC (biological safety cabinet).

4. Wipe the side of slide without the circle with alcohol swab.

5. Place the slide onto a heater to dry the slide.

6. Place a drop of saline on the slide.

7. If the specimen is too big, cut it and place it on the saline on the slide.

8. Use a swab to mix the specimen and saline together and spread the mixture.

9. Place the slide onto the heater to dry the slide.

ii) For culture for aerobic bacteria
By referring to the table above, different forms of specimens must be processed onto the correct medium. To know what form of specimen it is, refer to the request form.

a) If either ‘Fluid from’ or ‘Tissue from’ are ticked:

1. Referring to table 1, prepare the appropriate plates and medium.
So blood agar, macconkey agar, cooked meat and anaerobic plates will be used.

2. Dip a swab into the fluid or tissue, pick up the specimen and swab the specimen onto the top of the plate.

3. Repeat step 2 with the macconkey agar.

4. The anaerobic plates have to be shared between 2 specimens. So it has to be divided into half.

5. Swab the specimen onto the top left hand corner of the anaerobic plate.

6. Dip the swab into the cooked meat.

7. Break the stem of the swab and cap the cooked meat.

8. Streak the blood agar and macconkey agar.

9. Streak S. aerurs* onto the blood agar as shown below. The S. aerus will provide a factor that the blood agar lacks.

10. Streak only half of the anaerobic plate.

Note: So if there are 2 specimens sharing one anaerobic plate, it should look like this:

11. The blood and macconkey agar will be stored in the CO2 incubator while the anaerobic plate will be stored in the anaerobic jar.

* S. aerus is only streaked onto the agar plate if the blood agar is to be stored in CO2 conditions.

b) If ‘Swab from’ is ticked:

1. Prepare blood agar, macconkey agar and cooked meat only.

2. Use the swab to swab the specimen at the top of the agar.

3. Dip the swab into the cooked meat.

4. Break the stem of the swab and cap the cooked meat.

5. Streak both blood agar and macconkey agar.

6. Store the blood agar and macconkey in normal conditions without CO2.

c) If either ‘Wound from’ or ‘Pus from’ are ticked:

1. Repeat the steps from (a) but the anaerobic plates will not be used.

2. Store the blood agar and macconkey in normal conditions without CO2.

d) If the specimen is from the eye:

1. Dip a swab into the specimen if the specimen is watery or soft.

2. Swab the specimen onto the top of blood agar.

3. Streak the plate as shown above.

4. Streak S. aerus as shown above as the plate will be stored under CO2 conditions.

5. Store the plates in CO2 incubator.

Note: If the specimen is optisol media, cooked meat will be used addition to the blood agar.

e) If the specimen is from the genital:

1. Dip a swab into the specimen if the specimen is watery or soft.

2. Swab the specimen onto the top of the blood agar and macconkey agar.

3. Streak both plates.

4. Store the plates under normal conditions without CO2.

Note: If the specimen is from male urethra or it is discharge from urethra, GC plates must be used in addition to the blood and macconkey agar.

If the specimen is HVS or LVS (normally comes in a swab):

1. Use the swab to swab the top of the blood agar.

2. Dip the swab into LIM broth and break the stem of the swab.

3. Streak the blood agar.

4. Store the blood agar under normal conditions without CO2.

f) If the specimen is a catheter:

1. Transfer the catheter onto the side of the blood plate.

2. Roll the catheter over the blood plate to the other side.

3. Transfer the catheter back to the container.

4. Store the blood plate under normal conditions without CO2.

Note: Catheter is a plastic tube that is inserted into the body cavity.

Anaerobic plate incubation

Anaerobic plates are used to detect any bacteria that can grow under anaerobic conditions. So these plates are normally stored in an anaerobic jar at 35ْC. In the anaerobic jar, 3 things must be put in.

1. Anaerobic plates
   
2. Anaerobic sachet – This is used to create the anaerobic condition.
3. Dry anaerobic indicator strips – These are used to indicate whether the environment is anaerobic or not.

If the colour changes from blue to white = anaerobic condition

If the colour remains blue = no anaerobic condition

Problems faced

Being human, people filling in the request forms may also mistakes. So there are instances when the wrong specimen is sent, or the form is sent to the wrong place. So we must also rectify these problems.

Below, I have summarized the problems I have faced so far.

Problem	Solution	Reason
Test requested not stated.	Call the doctor to confirm the test wanted.	To prevent carrying out the wrong test and save resources.
Specimens sent to the wrong place. Example: 1. DR specimens sent to DM. 2. Request for MRSA screening. 3. Request for culture for fungus. 4. Request for culture for anaerobic bacteria. 5. Request for AFB test.	1. Bring specimen to DR station. 2. Bring specimen to MRSA screening station. 3. Bring specimen to fungus lab. 4. Put the request form with the specimen in the anaerobic basket meant for the anaerobic lab. 5. Put into a big basket to be sent out.	DM station is only in charged of gram-staining and culture for aerobic bacteria.
For fluid or tissue specimens: Request for culture for anaerobic and aerobic bacteria.	Request forms come in duplicates. Write ‘sent’ beside anaerobic bacteria on the orginal copy. Write ‘done’ beside aerobic bacteria on the duplicate copy. After processing specimen for aerobic bacteria, put the duplicate copy of request form with the specimen in the anaerobic basket.	DM station only in charged of gram-staining and culture for aerobic bacteria.
For swab specimens: Request for culture for anaerobic and aerobic bacteria but the swab is not in a gel.	Write ‘DRY’ beside anaerobic bacteria and process specimen for aerobic bacteria. Culture for anaerobic bacteria will not be done.	For culture for anaerobic bacteria, the swab must be put into a gel. Also, DM station is only in charge of gram-staining and culture for aerobic bacteria.
Request for gram-staining and culture for aerobic bacteria. But only 1 swab was sent in.	Write ‘MEND’ (microscopic examination not done) beside gram-staining and continue with culture for aerobic bacteria.	Normally 2 swabs are needed for both tests to prevent contamination.

Table 2

So that's all for now. I will update when there is more.

So have fun at your attachments!

-Li Ping =)-
TG o2

Quality criteria needed to achieve JCI accreditation

Quality criteria needed to achieve JCI accreditation:

Patient-Related:
• Consistent and optimal care from patient admission to discharge. [3]
• Ensure safety of patients, reducing risk in clinical processes. [3]
• Ability to assess patient needs and concerns through their medical, physical history, etc. [1]

Management-Related:
• Implementation of guidelines, policies for patient care, quality improvement, infection control and prevention. [1]
• Proper documentation of staff qualifications and training, patient information and data management. [1]
• Able to effectively assess performance by reviewing the 6 categories of risk management:
1. General safety and security
2. Hazardous materials and waste
3. Emergency management
4. Fire safety
5. Lab equipments
6. Utilities.[2]


References:
1. Hamami (2007). Joint Commission (JCI) Standards. Retrieved 8 June, 2008 from PharmaCorner Website: http://www.pharmacorner.com/default.asp?action=article&ID=925
2. Hamami (2008). Tracer Methodology: A New Approach to the Accreditation Survey. Retrieved 8 June, 2008 from PharmaCorner Website: http://www.pharmacorner.com/default.asp?action=article&ID=1409
3. Healthbase.com (2007). Medical Tourism FAQ. Retrieved 7 June, 2008 from https://www.healthbase.com/hb/pages/medical-tourism-faq.jsp#29

Malerie

What is JCI accreditation?

JCI accreditation is a process that JCI evaluates and gives recognition to the healthcare organizations if it meets the JCI accreditation standards.^[1] The process involves a JCI’s survey team, which consists of a physician, a nursing officer and an administrator.^[2] The team will take four days^[3] to inspect the written policies, documents, premises and departments of the hospital and also interviews key personnel regarding the policies and documents. The team will also meet the medical staff to discuss about their findings. The International Accreditation Committee will then analyze the survey and give the final say in the accreditation decision.^[2]

References:

1. Joint Commission International Web Site. (2002 – 2007). Accreditation. Retrieved 14 June, 2008, from http://www.jointcommissioninternational.org/22758/

2. Lim S. P. (2005). Understanding Hospital Accreditation: The Joint Commission International (JCI). Retrieved June 14, 2008, from http://www.sma.org.sg/sma_news/3701/commentary.pdf

3. Tsuen Wan Adventist Hospital Web Site. (2006). Accreditation. Retrieved 14 June, 2008 from http://www.twah.org.hk/en/jci.html

Lee Jin

Why need JCI accreditation? (Importance)

Joint Commission International (JCI) accreditation is able to assess and enhance the quality of patient care in international health care organizations, public health agencies, health ministries and others. By having JCI accreditation, it will indicate that the organisation is of known quality and that they follow all the required and accepted standards that are created for quality improvement. ^[1] It will also assure the patients that they are receiving quality care from health care organisation. Through JCI accreditation, organisation is also made available to various resources and services that will allow them to associate with the international community. ^[2]

References:

1. Joint Commission International Web Site. (2002 – 2007). Accreditation. Retrieved 16 June, 2008, from http://www.jointcommissioninternational.org/22758/
2. Joint Commission International Accreditation. (n.d). Improving health care quality and safety around the world. [brochure] Retrieved 16 June, 2008, from http://www.jointcommissioninternational.org/fpdf/international/JCI_Accreditation.pdf

-Shi Hui-

what is JCI?

JCI (Joint Commission International) is an accreditation organisation based in the United States that ensures hospitals that have been accredited have good quality facilities and technology. The aim of JCI is to help increase the quality of patient care and health care services worldwide. It does so through providing education and consultation services for hospitals, and also international accreditation to provide documented proof that medical facility accreditated is up to standard of the JCI..[1]
Examples of JCI consulting services: nursing, management, strategic planning, facility planning[2]
Examples of JCI education seminars: Asia Pacific Practicum I (Singapore)[3]

References

[1] Joint Commission International Web Site. (2002 – 2007). About Us. Retrieved 15 June, 2008, from http://www.jointcommissioninternational.org/23069/
[2] Joint Commission International Web Site. (2002 – 2007). consultation. Retrieved 15 June, 2008, from http://www.jointcommissioninternational.org/22759/
[3] Joint Commission International Web Site. (2002 – 2007). education. Retrieved 15 June, 2008, from http://www.jointcommissioninternational.org/24165/
Yuxuan

Benefits of JCI

When an organization gets accredited by JCI, it shows that the organization is committed to improving the quality of healthcare, by ensuring a safe environment and continual improvement of services to reduce risks faced by the staff and the patients. JCI accreditation is also recognized worldwide, as a way to effectively evaluate and manage the quality of the healthcare provided by an organization.^[1] JCI accreditation can also be used to assure consumers that whatever service they are receiving from that organization, is of good quality and is in accordance to a set of guidelines and standards. ^[2]

References:

1. Joint Commission International Web Site. (2002 – 2007). Accreditation. Retrieved 10 June, 2008, from http://www.jointcommissioninternational.org/22758/
2. Medical tourism/ Health tourism/ Plastic surgery/ Alternative medicine/ Cosmetic surgery. (2007). Understanding JCI credentials/ Accreditations. Certification/ International standard/ medical tourism/ hospitals. Retrieved 10 June, 2008, from http://www.placidway.com/article/55

- Li Ping =) -