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Management. Dr Ahmad Ashshi. Management. There are many definitions for management. Generally, management can be defined as “ an ongoing process that seeks to achieve the objectives of an organisation in the most efficient ways possible” .

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Management

Dr Ahmad Ashshi


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Management

There are many definitions for management. Generally, management can be defined as

  • “an ongoing process that seeks to achieve the objectives of an organisation in the most efficient ways possible”.

  • It may be also defined as “the attainment of objectives”.

  • It has been also simply defined as “controlling and organising an organisation and leading”.

    Based on the definitions we can define Medical Laboratory Management. It is, therefore, ‘an ongoing process that seeks to efficiently achieve the objectives of a medical laboratory. The objectives of a medical laboratory are providing its customers (physicians on behalf of patients) accurate answers which contribute to clinical treatment”..


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Every achievement of management is the achievement of a manager and every failure is the failure of a manager.

  • A good manager studies management as a daily practice. The high-performance manager is:

  • A strategist: one who looks to the future.

  • A Problem solver: one who uses his factors under his or her control to redirect the course of action to achieve the organisation objectives

  • A teacher: One who guides and helps others to identify and solves problems


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Medical Laboratory Managers

  • challenged to become business, as well as technical specialists. There are many pressures on the modern medical laboratories managers that may force it to not only keep up to date but to move ahead in preparation for the needs of the future. The work environment has changed with the development of new technology. Laboratories have always seen the need for change and development, there has been increased pressure to improve performance, tighten margins, improve quality and reduce costs


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Medical Laboratory Managers

  • Each laboratory must have a strategic plan that describes its long-term goals, such as a move toward more automation or molecular diagnostic techniques.

  • Each employee’s role should be clearly defined, and written job descriptions should be provided so personnel know what they are expected to do. Therefore, it is a not an easy task for a manger to strike a balance among the clinical laboratory regulations, fiscal responsibility, and employee competence and morale to maintain the overall quality of patient care.

  • it is appropriate to remember that the two most important components of management are

  • common sense

  • open communicationwith laboratory staff


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ORGANISATION OF CLINICAL LABORATORIES

  • Clinical Laboratories may be organised into different sections. The organisation depends on the site (public health hospital, physician office laboratory, or independent laboratory, etc.) and the complexity of testing. However, some general guidelines may be applied to a situation, and they are discussed as follows:

  • Microbiology Laboratory

  • Chemical & Biomedical Laboratory

  • Haematology Laboratory

  • Histopathology Laboratory

  • Molecular Biology laboratory


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Microbiology Laboratory

  • Clinical Microbiology comprises essentially seven sections.

  • Aerobic and anerobic bacteriology

  • Mycology

  • Mycobacteriology (also called Acid-fast Bacteriology, AFB)

  • Parasitology

  • Virology

  • Serology

  • Molecular diagnostics (PCR & DNA probe technology)

  • As it was mentioned before the organisation depends on many factors. The following is also another organisation which has divided a General Hospital Microbiology Laboratory into 11 sections as follows:


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Microbiology Laboratory

  • Sample Receiving & Processing SectionSamples brought to the clinical microbiology are at first received by this section. Here sample are received and the samples are processed according to the nature of the sample.

  •    Urinalysis SectionIn this section detailed report of urine samples including physical, chemical, microscopic examination is be prepared.

  •   Parasitology SectionParasitology section deals with intestinal parasites. Samples of faeces are examined here for the presence of any intestinal parasite. Slides are prepared here inside a safety cabinet.

  •   Serology SectionIn serology section immunological and serological tests are performed by different techniques like Latex agglutination, haemagglutination and antibody absorption.

  • Mycobacteriology Culture & Sensitivity SectionIn this section all TB smear, culture and sensitivity performed in two Biosafety II cabinets to avoid risk of infection


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  • Nose, Throat,  Sputum and Urogenital Cultures and Sensitivity SectionHere cultures of respiratory tract and genital tract infections are prepared.

  • Wounds Culture and Sensitivity SectionCulture of wound swab, pus, aspirates, body fluids including CSF are the responsibility of this section.

  • Urine Culture & Sensitivity SectionDifferent types of urine culture performed here including mid stream urine and catheter samples of urine. Each sample is processed and evaluated accordingly.

  • Blood Culture and Sensitivity SectionIn this section culturing of blood samples is carried out. Nowadays, this section is equipped by machines such as Bactec 9240, flourometric instruments. Each instrument is capable of running 240 samples at a time.


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Quality Control SectionIn this section quality control of water, food products and environment is performed with the help of different media and colony counters.

Mycology Culture SectionRequests for fungus smear and culture processed here in a bio safety II cabinet to avoid infection from fungal spore.

Regardless of the organisation of a Microbiology Laboratory, the main aim is providing the client (the physician) with accurate and reliable results to assist the process of clinical treatment.


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Personnel

  • LAB DIRECTOR :

  • He/She must be a physician or a doctoral scientist qualified to assume professional , scientific , consultative , organizational , administrative , and educational responsibility for the services offered by the lab .

  • If a non-pathologist physician or doctoral scientist service as director , he/she must be qualified by virtue of documented training ,expertise , and experience in areas of analytic testing offered by the lab .

  • He/She must have sufficient training and experience in clinical medicine , sciences basic to medicine , clinical lab sciences


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Personnel

  • The following directorial functions are :

    1- interpretation , correlation , and communication of lab data

    2- interaction with physicians and/or medical staff , patient , administration .

    3- monitoring of standard of performance , QC , QI.

    4- provision of education programs , planning , research.

    5- ensuring sufficient personnel with adequate documented

    training and experience to meet the needs of the lab .

    6- he/she must be decision-maker in the selection of all lab equipments and supplies .


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Personnel

  • If the lab director has delegated some responsibilities to others , there must be documentation of which individuals are authorized to act on his /her behalf for specific activities .

  • GENERAL SUPERVISOR :

  • Bachelor degree in chemical or clinical lab / medical technology science with at least one year experience .

  • Is reponsible for day-to-day supervision of the lab operation , as well as personnel performing testing and reporting test results .


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Personnel

  • ALL PERSONNEL :

  • There must be an organizational chart for the lab .

  • Personnel policies must be documented and available to all employees

  • The lab should have a complete , functional in-service continuing clinical laboratory education program .

  • Personnel files must be maintained on all current employees , the ideal location of personnel files in the lab .


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Personnel

  • Technical personnel records must include of all of the following :

    1- summary of training and experience .

    2- description of duties .

    3- records of continuing education .

    4- health record .

    5- incident records .

    The lab must conduct an annual performance review of all employees.

  • New employees must be reviewed within 6 months of employment .


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Personnel

  • Some elements of competency assessment of each person :

    1- Direct observation of routine patient test performance , including patient preparation , specimen handling , processing and testing ;

    2- Monitoring the recording and reporting of test results ;

    3- Review of intermediate test results or worksheet , QC results records ; PT results ; and preventive maintenance .


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Personnel

4- Direct observation of performance of instrument maintenance and function checks ;

5- Assessment of test performance through testing previously analyzed specimens , internal blind testing samples or external PT samples .

6- Evaluation of problem solving skills .


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Personnel

  • The lab must participate in an approved program of graded interlaboratory comparison testing appropriate to the scope of the lab.

  • So that it must be enrolled in the appropriate available CAP surveys or CAP-approved alternative PT program for patient testing performed.

  • External surveys samples should be run within the routine lab workload , and are analyzed by personnel who routinely test patient samples using the same primarily method systems as for patient samples.

  • Replicate analysis of surveys samples is acceptable only if patient samples are routinely analyzed in the same manner.


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The College of American Pathologists Laboratory Accreditation Program


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Personnel

  • If the lab uses multiple methods for an analyte surveys samples should be analyzed by the primary method.

  • There should be documented evidence of active review by the lab director or designated supervisor of the survey results.

  • For analytes where graded PT is not available , performance must be checked at least semi-annually with appropriate procedures such as : participation in graded proficiency surveys , split sample analysis with reference or other labs , assayed materials , regional pools .

  • It is responsibility of the lab director to define such procedure.

  • There must be evidence of identification and review of problems , and their solutions .


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Quality control and Quality improvement

  • The QC / QI program should be clearly defined and well-organized.

  • The QI program must provide the system design and evaluation of proper patient identification and preparation ; specimen collection ; preservation ; transportation ; storage before testing ; processing ; and accurate results reporting.

  • This system must ensure optimum patient specimen and integrity of the result throughout the pre-analytical , analytical , and post-analytical process.


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QI / QA “supervision

  • Judgment of the acceptability of QC data must be made at least monthly by the lab director or designee.

  • Because of many variables , the CAP makes no specific recommendations on the frequency of any additional assessment / review of QC data.

  • There must be evidence of active review of records of instrument function , temp , and maintenance , for all routine procedures on all shifts.


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QI / QA“SUPERVISION

  • The lab must have documented system in operation to detect and correct significant clerical and analytical errors.

  • One common method is review of results by a qualified person before release from the lab , but there is no requirement for supervisory review of all reported data.

  • The selective use of delta checks also may be useful in detecting clerical errors in consecutive samples from the same patient.

  • In computerized lab , there should be automatic alarm for improbable results.


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QI / QA “supervision

  • The system must provide for timely correction of errors before results become available for clinical decision making.

  • In the absence of on-site supervisor , the results of tests performed by personnel must be reviewed by the lab director , general supervisor , or person in charge of the chemistry lab on the next routine working shift.


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Laboratory investigation

Dr Ahmad Ashshi


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Introduction

  • MicrobiologySwabs eye, nose, throat, umbilical, ear, wound, rectal, urethral and vaginal) CSF (3 samples. First for culture, second for biochemistry and the there’d for cell count)

  • Parasitologyurine and stool)

  • Biochemistry (All chemistryin plane tube or heparins)

  • Hormones (All in plane tube or gel separating tube)

  • Hematology(EDTA Blood for CBC and Citrated Blood forCoagulation

  • Blood bank(ask for donor replacement for any bags used to the patient)(plane tube for crox matching and blood grouping)

  • Histopathology(complete identification & clinical details)


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الدم

يتكون الدم من جزئين صلب وسائل

الجز الصلب يتكون من كريات دم حمراء, كريات دم بيضاء وصفائح دموية

اما الجزء السائل فهو عبارة عن ماء + املاح ويتم اخذ الدم اما من الوريد او من الشريان

خطوات تجميع العينات

-1 ان يكون كل تحليل بأنبونة خاصة بة حسب طلب المختبر حسب الجدول

2- الشد النفسى أو العصبى ((GH, Cortisol, Glucose high

ان لايكون المريض مشدود نفسيا لذا لابد من تهدئة المريضذ

التأكد من اسم المريض, الملف, الانابيب التى يحتاجها حسب نوع التحلي -3


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- 4 يجب التأكد من الخطوات التالية قبل سحب العينة

* التعقيم بواسطة الكحل أو الايودين

* خلط محتويات العينة قبل ارسالها لعدم حدوث التجلط

* عدم رج العينة بشدة حتى لا يحدث التكسر للدم Hemolysis

* حجم الابرة لابد ان يتناسب مع البرواز

Tourniquet * طول ربطها, ربطها بشدة يؤثر على محتويات الدم وتكسيرة

* تجنب ان يتلوث غطاء الانبوبة , الوعاء او طلب التحليل بالدم

* عينات الامونيا, غازات الدم, باراثايرود هرمون توضع فى ثلج لمدة لاتزيد عن 4 ساعات

* فى حالة طاب F glucose, TG, UA لابد ان يصوم المريض لمدة 12 ساعة


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5- الوقت

A.اخذ العينات فى اوقت معينة مثال ذلك

·فى حالة العقم تؤخذ العينة فى اليوم الثالث FSH, LH

يوم 21 لتحليل progesterone

· for Cortisol samples 7-10 AM & 4-8 PM

Samples for GGT should withdrew in morning hours

نسبة الدواء بعد اخذ العينة

B.الحرص على اخذ العينات فى اوقات عمل المختبر وارسالها فى اسرع وقت

6- collecting specimen from canula and from limbs

receiving drips


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Technique

Venous stasis (tourniquet application) should always be minimised.

Cell counts, and the levels of proteins (including enzymes) and protein bound substances (eg. calcium, cholesterol, many drugs) will be increased by prolonged excessive venous stasis.

Venepuncture should be clean and atraumatic.

If difficulty is experienced, the attempt should be abandoned.

A second venepuncture (preferably by a more experienced collector) should be attempted with a new needle and syringe, or evacuated container, at a different site €€


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Tubes

Blood must be added to the tubes immediately but gently and without frothing.

If a syringe with needle is used, the needle must be removed before adding blood to the specimen tubes.

If tubes containing anticoagulant are used, the correct amount of blood must be added to the tube (usually indicated by a mark on the label) and mixed immediately by thorough, but gentle, inversion.

Tubes should never be shaken and blood should never be poured from one container to another.

Blood culture specimens should, if possible, be collected from a separate venepuncture site. If a single venepuncture is necessary, the blood culture bottles must be inoculated first.

The needle should then be removed for addition of blood to the remaining specimen tubes.

Specimen tubes should be labelled immediately after the specimen is collected


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Safety

All blood samples must be treated as potential infection risks.

Care should be taken to avoid over-filling of tubes which is likely to be associated with leakage of blood and contamination of the external surface of the container.

Needles must be disposed of with care into a 'sharps' container.

Syringes, swabs, or any other blood contaminated materials must be placed in an appropriate contaminated waste container immediately after use.

Evacuated collection systems are now frequently used for blood collection as there is less chance of blood spillage and thus exposure to blood-borne diseases


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Specimen transport

Blood samples should be transported to the laboratory in biohazard bags with minimum delay.

Rapid transport samples eg: PTH & glucose

If delay is inevitable it is generally better to refrigerate samples.

However refrigeration may itself cause artefactual changes in the results.

Samples which need ice and anaerobic condition eg: Arterial blood gases and ammonia)


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Electrolytes

Blood for electrolytes should not be refrigerated; if delay is anticipated, plasma should be separated and stored at 4°C.

Unseparated samples of blood must never be frozen.

Samples should not be subject to temperatures of >25°C, even for short periods.

Some tests involve especially labile components (eg, complement) and blood must be transported to the laboratory immediately


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Microbiological examination

Specimens for microbiological examination must be appropriate eg, sputum rather than saliva.

In general, specimens should be collected into, and transported in, a sterile container.

Aspirated pus may be transported in a syringe, which must be capped immediately the needle has been removed and disposed of safely.

Specimens should be delivered promptly to the laboratory.

Although many specimens will tolerate a delay of several hours if refrigerated, cerebrospinal fluid must be transported to the laboratory immediately, without refrigeration.

Similarly, for the detection of Neisseria gonorrhoeae and other fragile organisms, special arrangements may be needed: eg, express delivery, inoculation of plates at the time and place of collection, provision of special transport containers.

Special requirements, for individual tests, are noted in the Test listing


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Tube Guide


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Type of urine specimens

1)Random specimens(drug abuse)

2) First-morning(microscopic examination, b-HCG, 8-hours)

3) 24-hours specimen

Some analyses produce in different time though 24 hours of collection morning or noon like Creatinine, protein, Ca, phosphors and electrolyte (the sample must be refrigerated)

4) clean-catch specimen (MSU)for bacterial culture

5)catheter specimen

6)   suprapubic specimenespecially for infant

7)urine collected from children

collection bags with hypoallergenic skin adhesive


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If the sample left at RT

Ønormal bacteria will multiply producing contaminated sample

Øif the organism urase producer, ammonia release will increase Ph resulting in destruction of cells and cast

Øthe bacteria will break down any glucose

ØRBC, WBC, Cast will lyze

ØProtein conc will alter

ØBilirubin and Urobilinogen oxidized-not detected

ØUric acid and urate deposited to for oxalate or phosphate crystal


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specimen

container

instruction

sputum

Clean, wide nick

Early morning, cough deeply for sputum, for children gastric wash, delay of specimen TB, Pn, HI

Throat swab

Sterile swab

Not contaminated with saliva, no antibiotic by 8-hours

stool

Wide nick

Must be fresh sample within 2 hours

Rectal swab

For cholera alkaline peptone water

Blood culture

Bld culture bottle

Take the sample when tempt high, use iodine for sterilization, mix it and must reach the lab early, never refrigerated

semen

Clean and sterile

3-7 days of sexual abstinence, no condom, time of collection and deliver to the lab within 2 hour

Microbiological sample


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وقت سحب العينة

لة اهمية كبرى وتأثير مباشر على نتائج بعض التحاليل مثل:

  • تركيز كلا من iron, cortisol, ACTH أعلى في الصباح الباكر

  • بالنسبة لمزارع الدم وعينات فحص الملاريا يفضل أخذها حين ارتفاع درجة الحرارة في حدود 3 عينات فى اوقات مختلفة

  • بعض الطفيليات يفضل أخذ عينة الدم فى المساء

  • تحاليل كلا من: مزرعة البول و فحص البول الكامل و فحص البول للحمل فانه تجمع فى الصباح الباكر

حبس الدم لفترة طويلة

لزيادة وقت حبس الدم بالربط الضاغط لفترة طويلة تأثير على تركيز البروتينات وبعض العناصر الاخرى كما يؤخذ فى الحسبان عدم استخدام الرباط الضاغط مطلقا عند سحب عينة غازات الدم وكذلك عند سحب عينة دم لتقدير حمض اللاكتيك


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التوتر العصبى

ولة دور مؤثر فى نتائج Catecholamine وغازات الدم لذا يراعى عند سحب العينات أن يكون المريض هادئا

المجهود العضلى

Muscular effort

يؤثر المجهود العضلى على العديد من

العناصر الموجودة فى سوائل الجسم

اما بالزيادة أو النقصان كما هو موضح


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العوامل المؤثرة على النتائج بعد سحب الدم

  • التحللHaemolysis

    يقصد بة تكسر RBC نتيجة (ضغط العينة او رجها بقوة, استخدام ابر معدنية ذات قطر صغير لسحب الدم

  • التلوث

    تلوث العينة ميكروبيا او كيمياويا

  • بقاء العينة لفترات طويلة قبل ارسالها الى المختبر

    حيث تبدأ الخلايا الحية الموجودة في عينة الدم باستهلاك السكر و العناصر الأخرى

    كما تبدأ في أستغلال الأنزيمات الموجودة حولها لأتمام أستهلاك العناصر و المركبات مما يؤدي الى تناقصها و بالتالي أعطاء نتائج خاطئة . كذلك بقاء السائل المنوي فترة طويلة في الأستقبال مما يؤدي الى موت الحيوانات المنوية و عينة سائل النخاع الشوكي التي قد تموت فيها الكائنات الحية الدقيقة بعد سحب العينة بفترة وجيزة مالم تعامل بالسرعة اللازمة .


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Criteria for rejection of specimens

  • Missing or inadequate identiification

  • Insufficient volume

  • Specimen collected in wrong collection tube

  • Contamination

  • Inappropriate transport and storage

  • Unknown time delay


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