Practical problems in the standardization of clinical algorithms

1
Practical problems in the standardization of
clinical algorithms

• Workshop Discussion

2
Meningitis Indications for Lumbar puncture
(minimal) good practice guidelines Are these OK?
3
Doing a lumbar puncture (1)

• Qualified staff MOs COs.
• Procedure explained to parents (and child if old
  enough), parents should give permission and may
  want to be present.
• Where?
• Procedure should be done before treatment (other
  than emergency treatment) and where best
  coordinated with lab. (OPD / Ward?)

4
Doing a lumbar puncture (2)

• Equipment
• 21G (green) needle or in small infants a 23G
  (blue) needle.
• Skin disinfection (iodine / 70 alcohol)
• Sterile gloves and sterile paper
• 2 sterile bottles to collect 1ml CSF each (if lab
  able to do glucose a separate bottle is
  required).
• Sterile gauze and sticking tape.

5
Handling the specimen.

• Label both bottles with
• Name
• Date time
• IP number
• Together with completed request form CSF sample
  needs to reach lab in time so that examination
  begins within 1 hour. (May need to contact lab).
• Do not expose to sunlight or put in fridge
• After hours specimen should be left at room
  temperature in the lab for culture and antigen
  testing only if the delay in examination is gt 6
  hours.
• Record procedure and appearance in notes.

6
Pneumonia Indications for Blood culture
(minimal) good practice guidelines Are these OK?
7
Doing a Blood Culture

• Qualified staff MOs COs ( nurses /
  phlebotomists?)
• Procedure explained to parents (and child if old
  enough), parents should give permission.
• Where?
• Procedure should be done before treatment (other
  than emergency treatment) and where best
  coordinated with lab. (OPD / Ward?)

8
Doing a Blood Culture (2)

• Equipment
• 21G (green) needle or in small infants a 23G
  (blue) needle or butterfly and 5 mls syringe.
• Wash skin if very dirty with soap and water
• Skin disinfection (iodine / 70 alcohol)
• Cotton wool.
• Blood culture bottle (Bactec)
• Clean top with alcohol wipe and let dry
• Inoculate 3 mls blood using a clean needle

9
Handling the specimen.

• Label both bottles with
• Name
• Date time
• IP number
• Together with completed request form blood
  culture should be transported to lab as soon as
  possible.
• After hours specimen should be left in a
  laboratory or ward based incubator at 35-370C
• Record procedure in notes.

10
Critical features.

• These are admission procedures before inpatient
  treatment.
• Clinical guidelines for investigations are for
  advice, in each case the clinician seeing the
  patient makes the decision about investigation
  and talks with the caretaker.
• The procedure is wasted if the specimen does not
  go promptly to the lab.
• Appropriate safety measures should be in place to
  protect staff as for any procedure (eg. sharps
  bins).