REDUCING CONTAMINATED RESULTS OF LOWENSTEIN JENSEN CULTURE AT THE NATIONAL TUBERCULOSIS REFERENCE LABORATORY

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1 REDUCING CONTAMINATED RESULTS OF LOWENSTEIN JENSEN CULTURE AT THE NATIONAL TUBERCULOSIS REFERENCE LABORATORY Nsubuga Richard Kasule George William (Medium Term Fellows) MENTORS: Musisi Kenneth MoH/NTRL Dr Eric Ikoona Ministry Of Health Medium Term Fellowship Dissemination Workshop Speke Resort, Munyonyo: 22 November 2013

2 Introduction and Background NTRL Mission; To provide quality laboratory services and to strengthen the national laboratory diagnostic network Some of the tasks at NTRL: contribute to patient care by providing technical services for detection, identification and drug susceptibility testing of TB

3 Problem identification Average general contamination rate for LJ was 10.5% The acceptable contamination rate is 2-5% Within range for baseline samples But follow up contamination rate is high compared to baseline and affects mostly the general rate Effects of high contamination rate Delayed results Delayed time to start treatment Increased TB transmission Wasted resources on repeated tests

4 Problem statement and Quality Improvement target Average cont rate acceptable cont rate Improvement target To reduce the contamination rate to at least 6% in 6 months (Mar Aug 2013).

5 Root causes identified Days of media QC not tested in local setting Gaps in media preparation and sample processing SOPs Media sorting Manual procedure Mucoid samples Deviation from sample processing SOP Poor planning and stock management skills

6 Objective General objective To reduce average contaminated results of LJ from 10.5% to 6% Specific objectives To revise the media preparation and processing SOP To improve LJ media inventory management

7 Project implementation Incubated media for 2 days and 3 weeks Media preparation SOP revised manual media dispensing procedures, Sorting media at 3 stages 3 weeks of QC Process thick (mucoid) samples first Demonstrated effects of harsh processing procedure Leadership and management training Hired trainers Trained 30 staff on planning, delegation, coordination and team work Stock cards introduced Minimum stocks determined Prepared buffer media stocks Fig 1. Training Workshop

8 percent April 2013; automatic dispenser broke down June 2013; deviation from decontamination procedure RESULTS: General contamination rate after intervention Contamination rate reduced 10.5% to 8.2% Previous Average cont rate 10.5% (Sep 2012 Feb 2013) Current Average cont rate 8.2% (Mar 2013 Aug 2013) Acceptable cont rate (2-5%)

9 Results Media preparation SOP revised 3 stages of Sorting, Manual dispensing 3 weeks of QC incubation Revised de-contamination SOP Start with mucoid samples Improved stock management of media Minimum stock established Stock cards part of SOP Preparation of buffer stocks

10 Lessons learnt Chemical contamination established (harsh decontamination) Incubating media for 3 weeks reduces contamination Good to start with mucoid samples when processing Proper stock management reduces contamination Major causes of contamination may need to be analysed looking at Baseline and Follow up samples

11 Challenges Challenges Non functional Automatic dispenser Contamination increased in June (Chemical contamination) One autoclave functional for both infectious wastes and media utensils Solutions - Manual dispensing - SOP revised (AUTOMATIC DISPENSER BOUGHT IN NOVEMBER) Fig 1. Automatic dispenser - Provided evidence based data - Meetings with personnel - currently autoclaving them separately

12 Standardization and Future plans Standardization SOPs have been revised Become routine at NTRL May be adopted by other culture labs in Uganda Future Plans To reach improvement target (20% still remaining) Monitor contamination rates using new automatic dispenser Establish contamination rates for follow up samples at NTRL

13 Conclusion The average contamination rate reduced from by 21.9%; from 10.5% to 8.2%

14 Recommendations Buy automatic dispenser HAS BEEN BOUGHT Continuous improvement should now focus on follow up samples Strict adherence to SOPs including interventions Procure another or repair non-functional autoclave

15 Acknowledgements Institutional and academic mentors MakSPH-CDC fellowship program CQI Medium-term fellows NTRL administration and workmates