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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 35-39

Specimen collection: The art of laboratory science among the clinicians


1 Department of Microbiology, J N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Microbiology, SRMSIMS, Bareilly, Uttar Pradesh, India
3 Department of Community Medicine, J N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
4 Department of Obstetrics and Gynecology, J N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
5 Department of Surgery, J N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Web Publication18-Aug-2017

Correspondence Address:
Hiba Sami
Department of Microbiology, SRMSIMS, Bareilly, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_9_17

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  Abstract 


Background: Specimen collection plays an important role in getting timely and accurate results of the investigation required for diagnosis. It is therefore important to develop systems and routine to increase knowledge, attitude and practices (KAP) among health-care workers regarding proper specimen collection, transport and promote cost-effectiveness. This study was conducted to assess and increase the awareness about the importance of proper specimen collection and evaluate the 'KAP' about the compliance with proper specimen collection among post-graduate students of a tertiary care hospital in India.
Materials and Methods: A semi-structured questionnaire, pre-tested, self-administered, was used to access the KAP about specimen collection among resident doctors in our institution. The study population comprised resident doctors from different departments including microbiology, medicine, paediatrics, surgery, obstetrics and gynaecology and others.
Results: A total of 86 residents took part in the study. Overall knowledge of doctors was found good, but there were gross deficiencies in the KAP of resident doctors in areas of universal precautions, proper collection of specimens, part preparation for specimen collection, safety precaution, disinfection of working area, handling of blood and body fluid, hand washing, disposal of waste, handling and transport of specimens, dealing with sharp injury, dealing with blood spillage and hospital infection control practices.
Conclusion: A better understanding of infection control and hand hygiene among medical students and clinicians could play a major role in curbing disease transmission. This will help design an educational intervention programme which will further help identify problem areas in specimen culture.

Keywords: Infection control, knowledge, attitude and practices, specimen collection


How to cite this article:
Khan F, Sami H, Rizvi M, Shah M S, Khan T, Ahmad M, Sultan A, Shukla I. Specimen collection: The art of laboratory science among the clinicians. J Patient Saf Infect Control 2017;5:35-9

How to cite this URL:
Khan F, Sami H, Rizvi M, Shah M S, Khan T, Ahmad M, Sultan A, Shukla I. Specimen collection: The art of laboratory science among the clinicians. J Patient Saf Infect Control [serial online] 2017 [cited 2019 Apr 23];5:35-9. Available from: http://www.jpsiconline.com/text.asp?2017/5/1/35/213289




  Introduction Top


Laboratory tests serve as an aid to the clinicians for making correct diagnosis of the patient's illness. During recent years, there has been an intense worldwide debate on the inadequate patient safety in healthcare.[1] Specimen collection plays an important role in getting timely and accurate results of the investigation required for diagnosis. The aim of microbiologic evaluation is to provide accurate, clinically pertinent results in a timely manner, but the quality of the specimens submitted to the microbiology laboratory is critical for proper specimen evaluation. Improperly collected specimens can lead to false results (i.e., garbage in, garbage out) diverting the diagnosis and treatment in the wrong direction. Most of the errors in sample testing result from human mistakes occurring before the sample reaches the laboratory. All diagnostic information from the microbiology laboratory depends on the quality of specimen received. Consequences of a poorly collected and/or poorly transported specimen include failure to isolate the causative microorganism and recovery of contaminants or normal microbiota. Antimicrobial therapy based on such reports is to some extent responsible for a splurge of antimicrobial resistance.[2] To provide rapid information for diagnosis and therapy, and to allow the physician to determine if additional, better-quality specimens should be collected, direct specimen smears are often utilised to determine the quality of the specimen. A number of studies suggest that majority of the errors in laboratory medicine are linked to the pre-analytical phase, i.e. before the sample is analysed in a laboratory (46%–68.2% of total errors), while analytical errors (within the laboratory) and post-analytical errors (reporting and interpretation of results) are less frequent (18.5%–47% of total errors).[3],[4],[5],[6],[7] It is therefore important to develop systems and routines to increase knowledge, attitude and practices (KAP) among health-care workers regarding proper specimen collection, transport and promote cost-effectiveness.

This study was conducted to assess and increase the awareness about the importance of proper specimen collection and evaluate the 'KAP' about the compliance with proper specimen collection among post-graduate students of a tertiary care hospital in India.


  Materials and Methods Top


Study design

This cross-sectional study was carried out among resident doctors working at a tertiary care institution of North India. A semi-structured questionnaire, pre-tested, self-administered, was used to access the KAP about specimen collection among resident doctors in J N Medical College, Aligarh Muslim University, Aligarh.

Participants

The study population comprised resident doctors from various departments including microbiology, medicine, paediatrics, surgery, obstetrics and gynaecology and others. After obtaining clearance from the Institutional Ethical Committee, consents were sought and obtained from the doctors taking part in the questionnaire study, and each consenting doctor was handed the questionnaire to complete. The mean time for completing the questionnaire was 10 min. Confidentiality was assured and strictly maintained.

Questionnaire

Enquiry was made about KAP pertaining to the following points: (1) universal precautions including hand washing, (2) hospital infection control practices, (3) disposal of waste, (4) part preparation for specimen collection, (5) proper timing of specimen collection, (6) proper technique for collection of specimens, (7) storage and transport of specimens and (8) dealing with sharp injury. The questionnaire consisted of 18 questions; each pertaining to respondent KAP so that the above categories could be assessed. Each correct answer scored one and a zero was given to incorrect answers. Zero to eight meant poor performance; nine to twelve an average performance; thirteen and above a satisfactory performance. The KAP scores were calculated for each respondent.


  Results Top


A total of 86 residents took part in the study comprising 54 (62.8%) males and 32 (37.2%) females. Overall knowledge of doctors was found good, but there were gross deficiencies in the KAP of resident doctors in areas of universal precautions, proper collection of specimens, part preparation for specimen collection, safety precaution, disinfection of working area, handling of blood and body fluid, hand washing, disposal of waste, handling and transport of specimens, dealing with sharp injury, dealing with blood spillage and hospital infection control practices [Table 1].
Table 1: Questionnaire with offered answers and results

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On analysing the data, 46 (53.5%) out of the 86 doctors studied had good knowledge regarding above-said categories, 38 (44.2%) moderate knowledge and 2 (2.3%) poor knowledge [Table 2].
Table 2: Level of knowledge, attitude and practice scores of participants

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  Discussion Top


Consistency between health information and knowledge and between knowledge and practice is the cornerstone for the success of any health promotion or disease prevention program.[8] There are a few studies on KAP of residents on specimen collection. In tertiary institutions, resident doctors are primarily responsible for proper specimen collection and transportation to the laboratories for incubation and further processing. Therefore, they are expected to have good knowledge about the same by virtue of their training and practice.

In this study, more than half (53%) of the participants studied demonstrated good knowledge of specimen collection, while nearly 45% had moderate knowledge of the same. Only 2.8% of the residents included in the study had a KAP score of <8. However, there were few specified areas of knowledge regarding specimen collection where below expected performance was recorded. For instance was the knowledge regarding volume of blood to be inoculated in blood culture bottle as we often receive inadequate quantity of blood samples. Only 32% agreed that 1–2 ml blood should be inoculated in a 10 ml culture, most were in favour of 5–6 ml blood. Volume of blood to be inoculated per culture is the single most important variable affecting recovery of microorganisms from patients with sepsis. Various studies have confirmed that the more the volume cultured, the higher the rate of detection of bloodstream infection, reporting increase in yield from 0.6% to 4.7% per extra millilitre of blood cultured.[9] However, to prevent the inhibitors present in the blood from inhibiting the growth of bacteria on culture, 1–2 ml blood should be inoculated in a bottle with 10 ml media.[10] Human blood contains various factors or substances that can interfere with the detection of microorganisms, for example, host serum factors and also antimicrobial agents. Therefore, inoculated blood must be diluted to a point where these substances will have a minimal inhibitory effect. The required dilutional factor has been evaluated before and up to 10 times dilution has been recommended.[11] Time-to-time educational intervention might be necessary in the study area to bridge the gap in knowledge, thus improving the quality of blood culture result.

Other specific area where level of knowledge was below from expectation in this study was proper test that should be asked for detecting malarial parasite as only 44% agreed that peripheral blood smear is the gold standard for the diagnosis of malaria; the rest either opted for parasite lactate dehydrogenase assay test or quantitative buffy coat as the gold standard for the diagnosis of the same. It is known that microscopic detection and identification of Plasmodium species in Giemsa-stained smear remains the gold standard for laboratory diagnosis. Majority (60%) of the participant doctors believed that peak of fever is the correct time for collection of blood for peripheral blood smear examination for the detection of malarial parasite. The reason for this response may be because of the assumption that highest positivity of peripheral blood smear will be at the peak of fever. On the contrary, when peak of fevers occurs, schizonts burst and release merozoites which cannot be seen in peripheral blood smear. Such types of myths are responsible for false reports and inappropriate diagnosis and treatment as merozoites cannot be detected by microscopy of peripheral blood smear because they are sequestered from the peripheral circulation.

Another important area where awareness was much below expectation in this study was the knowledge regarding delay in transport of cerebrospinal fluid, only 40% doctors agreed that it should not be stored in refrigerator, 32% agreed with not storing the specimen on room temperature while 17% were in favour that it should not be stored in incubator. The reason for the lower performance on this question may be that most doctors, apart from the laboratory physicians, do not have sufficient knowledge of the processes in the laboratory. After the specimens are submitted to the laboratories, they are ignorant of the further procedures done on those samples. It is advised that all doctors, especially residents, are made to rotate through the laboratories to acquaint themselves with how specimens are further processed beyond reception, as during undergraduate teachings, the experience gained does not appear to be sufficient. In another questionnaire study on blood culture collection from Nigeria, researchers also found the importance of rotatory postings of clinical residents in laboratories to acquaint them with the importance of proper collection and transport of specimens.[7]

Regarding the practice of hand washing while dealing with patients, 86% agreed to perform it before and after every patient. Hand washing in the health-care setting has been promoted for generations and is recognised as the single most important procedure for preventing infection.[12] Feather et al.[13] observed the hand hygiene practices of 187 candidates during final MBBS Objective Structured Clinical Examination at the Royal London Hospital School of Medicine and Dentistry in the UK and found that only 8.5% of candidates washed their hands after patient contact, although the figures rose to 18.3% when hand hygiene signs were displayed. Dedicated and multifaceted efforts must be undertaken to rectify this attitude and behaviour. An improved understanding of infection control and hand hygiene among medical students and clinicians could play a major role in curbing disease transmission.


  Conclusion Top


The questionnaire could be used for assessment of 'near-miss' practices that could jeopardise specimens processing. A better understanding of infection control and hand hygiene among medical students and clinicians could play a major role in curbing disease transmission. This will help design an educational intervention programme which will further help identify problem areas in specimen culture.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bölenius K, Brulin C, Grankvist K, Lindkvist M, Söderberg J. A content validated questionnaire for assessment of self reported venous blood sampling practices. BMC Res Notes 2012;5:39.  Back to cited text no. 1
    
2.
Baron EJ, Peterson LR, Finegold SM. Selection, collection, and transport of specimens for microbial examination. Bailey and Scott's Diagnostic Microbiology. 9th ed.. St. Louis: Mosby-Year Book; 1994. p. 53-64.  Back to cited text no. 2
    
3.
Carraro P, Plebani M. Errors in a stat laboratory: Types and frequencies 10 years later. Clin Chem 2007;53:1338-42.  Back to cited text no. 3
    
4.
Fang L, Fang SH, Chung YH, Chien ST. Collecting factors related to the haemolysis of blood specimens. J Clin Nurs 2008;17:2343-51.  Back to cited text no. 4
    
5.
Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in laboratory medicine. Clin Chem 2002;48:691-8.  Back to cited text no. 5
    
6.
Plebani M. Errors in clinical laboratories or errors in laboratory medicine? Clin Chem Lab Med 2006;44:750-9.  Back to cited text no. 6
    
7.
Ojide CK, Onwuezobe IA, Asuquo EE, Obiagwu CS. Knowledge, attitude and practice of blood culture: A cross sectional study among medical doctors in a Nigerian tertiary hospital. Afr J Clin Exp Microbiol 2013;14:174-9.  Back to cited text no. 7
    
8.
Zaidi MA, Griffiths R, Beshyah SA, Myers J, Zaidi MA. Blood and body fluid exposure related knowledge, attitude and practices of hospital based health care providers in United Arab Emirates. Saf Health Work 2012;3:209-15.  Back to cited text no. 8
    
9.
Li J, Plorde JJ, Carlson LG. Effects of volume and periodicity on blood cultures. J Clin Microbiol 1994;32:2829-31.  Back to cited text no. 9
    
10.
Weinstein MP. Current blood culture methods and systems: Clinical concepts, technology, and interpretation of results. Clin Infect Dis 1996;23:40-6.  Back to cited text no. 10
    
11.
Dreyer AW. Blood Culture Systems: From Patient to Result. In: Azevedo L, editor. Blood Culture Systems: From Patient to Result, Sepsis – An Ongoing and Significant Challenge. South Africa: InTech; 2012.  Back to cited text no. 11
    
12.
Rameswarapu R, SurendranathSai K, Valsangkar S. Assessment of hand hygiene levels among healthcare professionals in India. Int J Biomed Adv Res 2015;6:107-9.  Back to cited text no. 12
    
13.
Feather A, Stone SP, Wessier A, Boursicot KA, Pratt C. 'Now please wash your hands': The handwashing behaviour of final MBBS candidates. J Hosp Infect 2000;45:62-4.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2]



 

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