6 CHAPTER VI: RECOMMENDATIONS AND CONCLUSIONS
6.2 RECOMMENDATIONS
6.2.2 Qualitative analysis
Introduce slide rechecking
Although proficiency testing is recommended as the most efficient means of making the first broad assessment of sputum smear microscopy in KwaZulu-Natal, rechecking a sample of routine smears from peripheral laboratories by the reference laboratory is considered the best method for evaluating performance and providing motivation to staff for improvement. [11, 48] Therefore blinded rechecking, of slides at regular intervals (at least quarterly), should be introduced as the next step towards optimal quality assurance.
Improve support visits
It is recommended that support visits be conducted at least once a year and more frequently, if significant problems are identified. Use of a standardised checklist is recommended as a tool for monitoring the performance of TB microscopy centres during support visits. The checklist described in the guidelines on external quality assessment for AFB smear microscopy can be used as a tool during support visits. [11, 22] All possible sources of
errors should be examined, including: quality of stains, quality of microscopes and
administrative procedures that contribute to recording errors. All possible causes of errors must be resolved. Possible causes of errors and suggested evaluation steps are illustrated in table 17.[11]
Improve communication
The reference laboratory should clearly communicate to the peripheral laboratories all the requirements expected from them. Issues such as who should process the slides, recording and reporting process as well as time frames should be clearly stipulated. A contact person in the reference laboratory should be appointed to address queries from the peripheral laboratories regarding issues of quality assurance.
The reference laboratory should clear any misperceptions regarding proficiency testing during training sessions and through newsletters. Managers should also be encouraged during meetings and through newsletters to improve communication between themselves and laboratory personnel reporting to them. TB coordinators conducting support visits should emphasise the principles of proficiency testing to laboratory managers and staff and encourage them to follow the rules/instructions of the programme.
Staff training
Several studies have shown that training improved laboratory performance, therefore remedial training is recommended for all laboratory technologists/technicians in laboratories that reported major errors.[13, 22, 31]Training should include smear
preparation and staining as well as various ways to identify faulty equipment, reagents and stains. Training should include maintenance of microscopes and other equipment as well as
infection control . It is recommended that quality assurance be included in TB training programmes for technologists and technicians as part of their in-service training.
Reassess staff allocations
Even the best technicians make mistakes when overloaded with work. [29] Therefore, an audit of staff providing TB diagnostic services should be conducted to establish their workload. Staffing at TB diagnostic centres should be optimised to ensure that adequate time is available to perform the various steps in TB diagnosis.
Improve feedback
Provide feedback to all participating laboratories as soon as possible after assessments are available. This is important to identify errors and implement corrective action immediately.
This would also keep participating laboratories/staff motivated and eager to continue, knowing that their efforts are making a difference.
Introduction of new technology to detect drug resistance
This recommendation is not based on the results, but on the literature review and the context of where we are in terms of the burden of TB and drug resistance in the province.
Due to the high TB drug resistance and TB-HIV co-infection in KwaZulu-Natal, it is recommended that the National Health Laboratory Services and the Department of Health fast track the implementation of the more rapid molecular assay techniques for rapid detection of drug resistance in isolates.
Feedback on findings of this study
Feedback on findings of this study will be provided to key role players including:
• National, Provincial and District TB Programme Managers
47 Infection control in this document refers to a comprehensive programme that encompasses all aspects of infection prevention and control including education and training, surveillance, environmental management, waste management, cleaning disinfection and sterilisation, and employee health.
• NHLS TB Quality Assurance Manager and all NHLS TB laboratory Managers and Staff.
Feedback will be in the form of a summary report highlighting the findings and recommendations. An academic paper/peer reviewed journal will also be drafted for publication and wider dissemination of the study results.
Table 17: Investigation of errors
Pattern of errors Possible cause
HFP and HFN 1. Unusable microscope 2. Staining problems
3. Technician cannot recognize AFB 4. Gross neglect
A single HFP 1. Administrative error 2. As for more frequent HFP Regularly a HFP or without 1. Poor registration routine LFP 2. Staining problems/fading
3. Technician unclear on AFB appearance
Rare LFP To be expected
Many LFP, with or without 1. Problem with controllers
occasional HFP 2. Technician unclear on AFB appearance 3. Contaminated stain reagents
Single high false negative 1. Administrative error
2. Very thick smears and/or poor light 3. Gross neglect
Frequent HFN and/or Many 1. Staining problems/Fading LFN 2. Poor smearing-technique 3. Problem with microscope 4. Careless microscopy
5. Contaminated stain reagents/water Very high proportion LFN Contaminated methylene blue or rinse water Many QE (too low gradings) 1. Poor staining
2. Problem with microscope
Suggested investigation steps 1. Examine a 3+using that microscope 2. Check stains and staining procedure
3. Test with clear-cut pos / neg and good microscope 4. Exclude other cause
1. Compare lab-register with QC-listing: correct slide number and result?
2. Exclude causes of more frequent HFP
1. Check accuracy of lab-register and other record keeping
2. Check stains and staining procedure, consider re-staining for rechecking 3. Look for inconsistent results of suspects (regularly single pos./low positive) in
lab register
No investigation unless numbers increase 1. Evaluate controllers
2. Recheck special sample of LFP from laboratory register 3. Test stain with known negative smears
1. Compare lab-register with QC listing : correct slide number and results?
2. Evaluate quality of smear preparation, check microscope 3. Exclude other causes
1. Check stains and staining procedures, consider re-staining for rechecking 2. As above, single HFN
3. Check microscope with positive slide 4. Exclude other causes
5. Test stain with known negative smears As above
As above As above