SUDANNTP Microscopy network and AFB quality assurance

1
SUDAN-NTPMicroscopy networkand AFB quality
assurance

• Overview of Sudan-NTP microscopy network
• 2. Quality assurance on Sudan-microscopy
  network.

2
Sudan NTP Microscopy network

• One TB National Reference lab.
• 22 State TB Reference lab.
• 297 peripheral TB laboratories.

3
Laboratory workload in 11 states 2002

• Average Slide Positivity rate 10
• Average workload 2000Average workload
• No of slides done/
• No of laboratories

4
Tasks of TB National Reference Lab-

• 1- Maintaining high proficiency in routine smears
  microscopy carried out at peripheral health
  facilities.
• 2- Training of laboratory staff involved in the
  national laboratory network for tuberculosis.
• 3- Surveillance of anti-tuberculosis drug
  resistance.
• 4- Collaboration in research activities.

5
Tasks of State TB Reference Lab-

• 1- Preparation and distribution of the stains to
  peripheral laboratories in the state.
• 3- Training of local lab.assistant.
• 4- Supervision activities.
• 5- Implementation and follow up of the Quality
  Assurance of sputum microscopy.

6
Tasks of peripheral TB Laboratory-

• 1- Examination of sputum smears by Z.N technique
  .
• 2- Registration of results in lab register book.
• 3- Keep slides for E.QC.

7
Organogram of Sudan NTP network
NTP Manager
NPHL Director
Decision on priority activities,research
protocols,budgets
Equipments transport
Utilizes supplies
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Supervision-

• Supervision is a key element of TB control and is
  considered the corner stone for sustainability of
  different NTP activities.
• Effective supervision will ensure
  sustainable,high quality services.
• Supervision can also be seen as a tool to achieve
  the NTP objectives.

9
The specific objectives of supervision in the NTP
laboratory network

• Provide support to health staff in order to
  improve their skills and performance.
• Monitor the implementation of NTP activities.
• Ensure high quality performance.
• Help solve problems related to sputum microscopy.
• Provide on job training.
• Share ideas.

10
Levels of supervision

• The NTP carries out supervision at the following
  four levels.
• 1- Central level.
• 2- State level.
• 3- province level.
• 4- Microscopy centers.

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The Frequency of supervision is done as

• TCU St (Once per year)
• St.C Pr.C (Quarterly)
• Pr.C TBMU (Monthly)
• Regular supervision is vital to NTP
  success.Feedback between different levels of the
  NTP is necessary to maintain staff motivation and
  quality of services.

12
Training
Objectives of Training-

• 1- To train and retrain lab staff on sputum
  microscopy.
• 2- To implement new technique.
• 3- To exchange the experience between different
  levels.

13
Levels of Training -

• 1- International level
• sending local NTP staff to attend external
  courses or workshops.
• inviting external expertise to carry out
  workshops to NTP staff in the Sudan.
• 2- National level (SNTBRL).
• 3- State level (state team in target states).

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Quality Assurance System
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Definition of Quality Assurance

• It is a system designed to continuously improve
  the reliability and efficiency of laboratory
  services.(WHO-IUATLD).
• A quality assurance program for AFB smear
  microscopy has several components.

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Objectives of External Quality Assurance by blind
rechecking

• Quality Control of routine smears.
• Continuous motivation and education.
• Improve quality by screening for unaccepted
  performance and problem solving.
• Complementary to on-site evaluation.

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NTP LABORATORY QUALITY ASSURANCE System
SYSTEMATIC INTERNAL MONITORING OF WORK (INCLUDING
TECHNICAL procedures,equipments TS AND STAINS
Analysis of smear microscopy(to remove obstacles
towards success
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Q.A system in Sudan NTP

• In last five year the SNRL collect 100 (all)
  positive slide and 10 from negative slide then
  all slides rechecked again by SNRL staff .
• Now the SNTP implemented QA system by Blind
  Rechecking of slides

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Steps of E.QA by Blind Rechecking of Slides

• 1.Slides keeping-
• Keep all slides whatever the result
  (representative)
• Each slide must be identified by number of slide
  and number of patient as obtained in the lab
  register book of TBMU.
• No result must be appear on slides (Blindness).
• Slides should be kept according to their number.
• Once a sample was collected, the remaining slides
  should be discarded

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2. Taking a sample(I)(State QCC

• Quarterly from slides of previous quarter
• Sample(random) size is a fixed number, according
  to LOTS quality assurance sampling technique it
  depends on frequency of smear negative and slides
  positivity rate
• First identify sample slides in lab register
  book start with a random number each time
• Use the master form(form1) to list these slides
  identification numbers(ID) and their results and
  make another copy without results.

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2. Taking a sample(II) (State QCC)

• Collect slides from the slide boxes, mark missing
  slides as such in the remarks column and replace
  them by the next slide
• Arrange slides in the transportation box
  according to their ID
• Bring slides to state lab. Coordinator with a
  copy of master form without results

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3. Blind rechecking(state lab.coordinator -first
controller)

• Should clean all slides with Xylene
• Restaining to all selected slides
• Recheck all selected slides, reviewing the same
  number of fields as should have been done in the
  TBMU
• List the results on the master form and gives
  results to state quality control officer.

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4. Identification of discordants (State QCC)

• Add state TB lab coordinator results to form 2,
  and compare with TBMU results using the errors
  cross-table
• Identify all slides with discordant results
• Make a list of those per TBMU on the discordants
  form, alternating column from time to time ( so
  part of TBMU and part of state TB lab coordinator
  results in each of the first two columns)
• Request these slides from the state TB lab, and
  send them to National TB reference lab together
  with the discordants list(form 3)

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5. National reference laboratory( second
controller)

• Controller are given slides plus discordants list
  to guide their work these controllers must have
  plenty of time
• All discordant slides must first restained
• Readings should then be added to discordants
  list(form3) and then returned to each state with
  the slides.

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HOW TO CONDUCT LAB QUALITY ASSURANCE BY BLIND
RECHEKING
CHOOSE SAMPLE SLIDES FROM LAB. REGISTER BOOK
FILL 2 COPIES OF FORM 1. ONE OF THEM WITHOUT
RESULTS
GIVE SAMPLE SLIDES TO STATE LAB COORDINATOR (1ST
CONTROLLER)COPY OF FORM 1 WITHOUT RESULTS TO BE
FILLED
1
2
3
Fill form 3(one copy for the whole state) and
send it with discordant slides to TB reference
lab(2nd controller)
DOWNLOWD BOTH READINGS INTO FORM 2 (one COPY for
each microscopy center)
Identify discordant slides from each TBMU
5
6
4
Complete form2 for each TBMU and discuss results
with state coordinator and TBMU personnel
TB reference lab to complete form 3 and return
it with slides to states
7
8
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7.Quarterly feedback to TBMU (State QCC)

• Send to TBMU a copy of (form2) together with
  slides with serious errors for review.
• No Error of any type
  optimal performance .
• Major Error HFP or HFN
  Unacceptable Performance
  (Evaluation and Corrective Action)
  .
• Minor Errors Quantification errors , LFP or LFN
  should not exceed predetermined level.
  

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SUDAN NTP
Organogram explain different Levels of E.QA
Peripheral level Peripheral microscopy centers
random sample State Q A Coordinators
Feed-back
intermediate level First level controls States
Q A Laboratories
Feed-back
5-10 discordant
National level Second level countercheck TB
reference lab
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Prpblem in QA-

• 1- Labeling and keeping of slides.
• 2- Collection of slides from TBMU.
• 3- Sending of discordant slides from states to
  NRL.

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Constrains-

• Defficiency of staff at state level.
• Lack of spare part (there is no fund).