Care prevention and management of tuberculosis

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Identifying TB > Sputum testing
  • Standard statement
  • Rationale
  • Resources
  • Professional practice
  • Outcome
  • References

The patient produces good quality sputum specimens, delivers them to the appropriate place at the appropriate time and returns for the results.

 

tb culture
   
Collecting a sample for smear microscopy (click to view)
Good specimens – i.e., are sufficient (3-5ml) and contain solid or purulent material - are required to give the laboratory technician the best chance of seeing AFB under the microscope and, therefore, for the service to identify the most infectious patients. If the sample is inadequate (e.g. saliva only) it may not be possible to see AFB even if the patient is infectious.
learn more Presentation: Collecting a sputum sample
read more Read more: Union (2007), Priorities for Tuberculosis Bacteriology Services in Low-Income Countries: Chapter 2 Sputum Smear microscopy

 

sample
Collecting a sample for culture and DST (click to view)
Although routine culture and DST are not available in many countries there will be times (when drug resistance is suspected or when a drug resistance survey is taking place) when sputum specimens need to be collected to carry out these tests. TB bacilli need to be viable in order to grow on culture so the specimen has to be treated more carefully than one collected for smear microscopy. While tubercle bacilli remain acid-fast over time (even when exposed to extreme heat) they will rapidly lose their viability due to contamination or overheating. The specimen must be transported to the laboratory and processed within three days of being collected. If the specimen cannot be sent to the laboratory immediately following collection, it needs to be stored in the coolest place possible. The three day limit can be extended with the use of a decontamination agent such as cetylpyridinium.
read more Read more: Union (2007), Priorities for Tuberculosis Bacteriology Services in Low-Income Countries: Chapter 4 Surveillance of anti-tuberculosis drug resistance
patient
Documentation and follow up (click to view)
Accurate documentation is essential to save time and prevent errors. It is vital that the correct information is written on the sputum request form and that the side of the sputum container is clearly labelled to ensure that there is no confusion either when the specimen goes to the laboratory or when the result comes back. If a mistake is made during this process, the patient may end up receiving the wrong results and/or being given the wrong treatment.
learn more Presentation: Documentation and follow up
documentation View Request form and laboratory register for sputum culture and DST
learn more Learn more: Analysing results and defining cases
read more Read more: Guidelines Fourth edition.pdf WHO (2010) Treatment of tuberculosis Chapter 2. Case definitions
Chapter 4 Definitions: case registration, bacteriology and treatment outcomes in Guidelines for the programmatic management of drug-resistant tuberculosis
tb

Do you have the resources required for best practice?

Best Practice Requirement

Your Current Practice

Identify gaps in your practice

A functional, well-stocked laboratory is able to carry out sputum smear microscopy on a daily basis with a system in place for quality
assurance

The health-care worker responsible for ordering tests has the necessary knowledge and skills to instruct the patient how to produce a good specimen and when and where to deliver it

The appropriate sputum containers are available – wide-necked, disposable containers with screw-top lids
Sputum request forms and laboratory registers are available and completed promptly by competent staff members

There is a place to store specimens safely if they are kept in a clinical setting before being sent to the laboratory

If the laboratory is not on-site, transport should be available to deliver the samples safely and as quickly as possible. If transport is not available, the patient can be given clear instructions as to precisely where specimens should be delivered
A system is in place for the prompt feedback of results, preferably with someone from the management unit routinely collecting the results.
A named staff member is responsible for coordinating the process with a deputy to cover absence

Good communication is maintained between the laboratory and the management unit

 

Best Practice for sputum collection

Best Practice Requirement

Your Current Practice

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The body of the container is clearly labelled, before it is used

Details should include the name/code of health facility and the name of the patient, the date the sample was received and whether it is sample 1, 2 or 3 (this information may vary but should beconsistent)

Sputum Collection

Best Practice Requirement

Your Current Practice

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The reason for collecting the specimen is explained to the patient

Each step is explained fully and slowly, in language that the patient can understand

The patient is encouraged to rinse their mouth with water, especially if they have been eating food, before expectorating into the Container

The labelled container is given to the patient

The patient is asked to be careful to direct the sputum into the container to avoid contaminating the outside for hygienic and safe handling

The health-care worker demonstrates a deep cough from the bottom of the chest, beginning with deep breathing

The health-care worker supervises the collection, but without standing in front of the person attempting to produce the sputum

The lid on the container is closed carefully and tightly

The specimen is checked by the health-care worker with the patient present – if it is insufficient (e.g., saliva only) the patient is asked to cough again and add to it.

Prevention of transmission

Best Practice Requirement

Your Current Practice

Identify gaps in your practice

The health-care worker supervises the collection, but without standing in front of the person attempting to produce the sputum

The patient and the health-care worker wash their hands with soap and water after collecting the specimen

The specimen must be handled carefully and the lid closed tightly

Ideally, there should a separate well-ventilated area for sputum collection, preferably outside the building, avoiding use of the
toilets

Care should be taken during the processing and disposal of the sputum specimen

Sputum Storage

Best Practice Requirement

Your Current Practice

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The specimen is sent to the laboratory as soon as possible after collection

The dates on which the specimen was collected and on which it was sent to the laboratory are recorded

If necessary, the patient is advised how to store a sputum specimen safely at home to prevent contamination, i.e., the lid is tightly closed and the container is kept out of the reach of children

Documentation

Best Practice Requirement

Your Current Practice

Identify gaps in your practice

The specimen is categorised as pre-treatment or follow-up

The sputum examination request form is completed accurately and the reason for the request is clearly marked, i.e., for diagnosis or follow-up, indicating the month (usually month 2 or month 5) of treatment

The laboratory register is completed clearly and accurately

Dates of the taking of specimens are entered into the laboratory register, the TB register and the patient’s treatment card as appropriate

Dates of results and the results themselves are recorded promptly and accurately into the laboratory register, the TB register and the patient’s treatment card as appropriates

 

The relevant number of good quality sputum samples will be received by the laboratory for investigation. A system will be in place (including an agreed turnaround time from receiving specimens to reporting results) to ensure that results are fed back accurately and without delay. From the laboratory register it will be possible to see how many specimens were examined per patient and the percentage of positive results among patients coming for diagnosis or for follow-up. There will be a correlation between the laboratory register the TB register and the patient treatment cards.
Action planning:

Use the following box to develop an action plan on how you will
improve your practice with regards to taking a sputum sample from a patient

Things you will change when explaining to the patient why and how to produce sputum samples

Things you will change about the way you record and follow up sputum sample results

Things you will change about how others in your team collect, record and follow up sputum samples taken from patients

List yours and others training needs and identify how you will address them to enable best practice during sample collection

 

 

produced in collaboration with city university
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