KAN-TN-LM 02 KAN TECHNICAL NOTES ON MEDICAL LABORATORY …kan.or.id/unduh/PALLI/Technical...

KAN-TN-LM 02

KAN TECHNICAL NOTES ON MEDICAL LABORATORY IN THE FIELD OF CLINICAL MICROBIOLOGY

Issue Number: 3 April 2016

Komite Akreditasi Nasional National Accreditation Body of Indonesia Gedung I BPPT Lt. 14 JI. M.H. Thamrin No. 8, Kebon Sirih, Jakarta 10340 - Indonesia Tel. : 62 21 3927422 Fax. : 62 21 3927528

Email Website

: [email protected] ; labmedik [email protected] : www.kan.or.id

VKAN -KAN-TN-LM 02

Reviewed by

Approved by :

Issue Number: 3 7 April 2016

APPROVAL SHEET

~ ' Quality Manager of National Accreditation Committee of Indonesia (KAN)

~' Director of National Accreditation Committee of Indonesia (KAN)

Dokumen ini tidak dikendalikan jika diunduh/ Uncontrolled when downloaded

~KAN KAN-TN-LM 02 Issue Number: 3 7 April 2016

LIST OF AMENDMENT

Part Number Part

No. Date Revised

Brief Description of Changes Revision Number

1 January 2008 All SR.LM.KAN 002 was revised as a whole

1 (except introduction) Identification

2 7 April 2016 document Identification document changed to KAN-

2 KAN-R-LM TN-LM 02 02

3 7 April 2016 Clause 1 Insert the term "safety" including "biosafety

1 and biosecurity"

4 7 April 2016 All Replace "Analyst" into "Technician" 3 - Add " ... certificates of training .. " - Delete " ... health analysis vocation .. " - Add "d v Appropriate numbers of

5 7 April 2016 Clause 2 laboratory technician (1 laboratory

1 technician handles for 1 - 15 specimens)"

- Restructure e until j into e by adding "biosafety and biosecuritv"

6 7 April 2016 Clause 3 a iii Replace " .. . resistant.. " into " ... clean, dry .. " 1 - Restructure 3 a iv and 3 a v into "3 a iv

Design laboratory is complied with a regulation on Health Minister Decree

7 7 April 2016 Clause 3 (KMK No. 1244/Xll/1994)."

1 - Add b - Restructure 3 c and 3 d into 3 c and

replace the term "chamber'' into "bioloQical safety cabinet"

8 7 April 2016 Clause 5 d Add " ... . and calibrated routinely." 1 9 7 April 2016 Clause 5 k ii Delete " ... . when aooropriate. " 1

Replace "Clin ical microbiology, standards

10 7 April 2016 Clause 61 and reference materials and cultures ... "

1 into "Reference cultures (stock cultures, lyophilized) ... " Delete "Clinical microbiology .. " and " .. . of

1 11 7 April 2016 Clause 6 m clean media."

Replace "areas" into "room" 2

ii


~KAN KAN·TN·LM 02 Issue Number: 3 7 April 2016

KAN TECHNICAL NOTES ON MEDICAL LABO RA TORY IN THE FIELD OF

CLINICAL MICROBIOLOGY

1 INTRODUCTION

a This technical notes are an interpretation of the general requirements of

SNI ISO 15189:2012.

b This accreditation technical notes are applicable to clinical microbiology

examination. Clinical microbiology is concerned with the investigation,

diagnosis and, in an advisory capacity, management of infection caused

by microbes (viruses, bacteria, parasites and fungi).

c These examinations also include procedures for determining, measuring

or otherwise describing the presence or absence of various substances or

micro-organisms. Facilities which only collect or prepare specimens, or

act as a mailing or distribution centre, are not considered to be medical or

clinical laboratories, although they may be part of a larger laboratory

network or system.

d This accreditation technical notes are applicable to collection , transport of

a clinical specimen for examination or processing, quality control , quality

assurance and requirements for safety (biosafety and biosecurity) in the

laboratory of clinical microbiology.

e Clinical microbiology are examination of microbes, which are unicellular or

cell-cluster microscopic organisms. That are taken to include detection,

isolation, enumeration, identification of pathogens and antimicrobial drug

assays.

2 PERSONNEL

a The Laboratory technician has been working in clinical microbiology areas

at least two years with certificates on training of microbiology techniques.

b Technical manager, laboratory supervisor and laboratory technician shall

possess a basic education in biological analysis, or a related science.

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c The laboratory shall be directed by person who has executive responsible

& competence to assume responsibility for the services of clinical

microbiology test.

d Laboratory management shall ensure that:

Appropriate numbers of laboratory personnel, with the required

education & training, to meet the demands of the service to

customers.

ii Laboratory personnel have the knowledge, skills, and abilities based

on education, experience, demonstrated skills, and training to perform

their duties.

iii Laboratory personnel had trained in handling pathogenic agents,

biosafety precautions, procedures for sample collection and handling,

media preparation, sterilization and data handling.

iv Full educational and professional records of all technical staffs

available to confirm their competence in clinical microbiology testing.

v Appropriate numbers of laboratory technician (1 laboratory technician

handles for 1 - 15 specimens).

e The training procedure is applicable to new employees, for the introduction

of new procedures, methods, biosafety and biosecurity, for retraining of

employees, and for re-verification of employee performance.

3 ACCOMMODATION AND ENVIRONMENTAL CONDITIONS

a The laboratories are designed to:

Provide space, engineering controls, and proper environmental

conditions for optimal sample storage, sample handling, and analyses,

in accordance with microbiology laboratory practices.

ii Minimize areas with cracks or fibers that could serve to accumulate

debris and serve as an area for growth of microorganisms.

iii Floors in the laboratories are constructed from a material that is clean ,

dry and easily disinfected.

iv Design laboratory is complied with a regulation on Health Minister

Decree (KMK No. 1244/Xll/1994).

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b A suitable environment is complied with a regulation on Health Minister

Decree (KMK No. 1244/MENKES/SK/Xll/1994 and KMK No.

1204/MENKES/SK/X/2004) for the tasks carried out clinical microbiology

testing. Laboratory shall have:

Distinct space, in line with the biosafety requirements, for performing

clinical microbiology testing.

ii Facilities that meet the required environmental conditions, including

any needed separation of work areas to ensure that analyses will not

be adversely affected within resources provided.

iii Good ventilation is necessary for the protection of the personal from

airborne infectious nuclei. The best way to ensure ventilation is by

use of windows and doors, ensuring that expelled air flow to the

outside environment. To ensure proper ventilation in closed-off rooms

an extraction fan will be required.

iv Written policies for handling spills of contaminated materials.

v Laboratory storage areas provide proper storage of samples,

reagents, microbiological media, select agents, standards and

reference materials, and hazardous waste procedures and facilities in

place for collection , storage and disposal of biohazard waste.

vi Laboratory monitored and documented the air quality of work places

where clean operation is expected (if there are any related

references on air quality of microbiology places, they can be

inserted).

c Laboratory shall have separate location provided for:

sample receiving

ii sample collection

iii sample/specimens preparation

iv sample examination (manipulation of pathogens relevant to their

hazard level and appropriate biological safety cabinet for handling

bacteria that highly contagious by air-borne routes. Special designs

are required for mycobacteria, mycology, and virology laboratory)

v media preparation

vi cleaning of lab-wares, decontamination and sterilization

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vii molecular microbiology (if laboratory has a biomolecular

examination).

4 TEST METHOD AND METHOD VALIDATION

a The test method are based on the valid method or reference method and

adequately documented, including:

title and method number,

ii scope and field of application,

iii number of revision,

iv page numbering, total number of pages,

v references,

vi principles and definitions,

vii reagents and materials,

viii apparatus,

ix analytical methodology,

x expression of results,

xi performance criteria,

xii storage and shelf-life,

xi ii procedures for media preparation,

xiv procedures for maintenance of stock cultures,

xv procedures of safety for media handling,

xvi quality control ,

xvii colony counting,

xviii reporting criteria,

xix issuing authority.

b The microbiological test method number and title used in the laboratory

shall the same as the scope of testing when carry out assessment for

accreditation.

c The validation of microbiological test methods should reflect actual test

conditions. This may be achieved by using naturally contaminated products

or products spiked with a predetermined level of contaminating organisms.

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d The validation of microbiological test methods needs for non-standard

methods and laboratory-developed methods. This activity is planned and

assigned to qualified personnel.

e The method's performance characteristics are based on the intended use

of the method. Method that used for qualitative microbiological test

analysis there does no need validate the method's linearity over the full

dynamic range of the equipment.

f Qualitative microbiological test methods, when the result is expressed in

terms of detected I not detected and confirmation and identification

procedures, should be validated by determining, if appropriate, the

specificity, relative trueness, positive deviation, negative deviation, limit of

detection, matrix effect, repeatability and reproducibility

g Quantitative microbiological test methods, the specificity, sensitivity,

relative trueness, positive deviation, negative deviation, repeatability,

reproducibility and the limit of determination within a defined variability

should be considered and, if necessary, quantitatively determined in

assays.

h Determination of microbiological test methods performance characteristics

for the validation of non-standard and laboratory developed methods

recommended following:

Meet method system suitability requirements, if applicable. The

suitability of the method is checked and confirmed by comparing with

requirements typical for the intended use of the method. Such as, a

filtration method for a non-filterable food, surface tests for Colony

Forming Units /square area where CFU/gram is needed.

ii Include un-inoculated medium control to assess contamination from

the laboratory. This control is considered a blank and is to exhibit no

growth.

iii Prepare and analyze positive and negative culture controls.

Negatives control is a typically negative or no growth and the positive

control is positive or shows microbial growth.

Spike positive culture control is prepared and analyzed. This assesses the

matrix effects as well as the sensitivity of the method. It is recommended

that a 25 gram sample be spiked with inoculums of 30 cells or less.

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Evaluate interferences. This assesses the selectivity and specificity of the

method.

k Laboratory shall have:

ii Written procedures for the proper collection and handling of sample

and organism including personal safety and spill handling.

iii Preparation procedures, protocols and quality control programs for

in-house media.

iiii Procedures and records of media preparation.

Method is validated or verified in laboratory thorough:

Qualitative tests are based upon performance history and media QC.

ii Repeatability - estimated using a minimum of 10 replicates of a

known positive sample, or duplicate data collected over a period of

time.

iii Estimation of measurement uncertainty.

iv Successfully participate in proficiency testing.

m Quality control programs for in-house media

Physical appearance.

ii pH checking.

iii Sterility results after incubation.

iv Performance checks using positive and negative control organisms.

n Supporting work instructions shall available to:

work instructions for sample disposal,

ii work instructions for disinfection I sterilization and disposal of

biohazardous material,

iii work instructions for glassware cleaning and sterilization,

iv work instructions for equipment instruction manuals,

v work instructions for computer software related data entry and

approval.

5 EQUIPMENTS AND MEASUREMENT TRACEABILITY

a Laboratory shall have:

List of the major equipment including specification, date received,

manufacturer, price, and maintenance service.

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ii Procedure specifies the schedule and requirements for maintenance,

performance, calibration, and verification of laboratory testing

equipment that meet the criteria of the maintenance and calibration

parameters needed to achieve the accuracy of instruments used for

analytical testing.

iii Equipment records containing description of the instrument, critical

accessories and software, manufacturer's name, type identification

and serial number; laboratory number; installation qualification (IQ)

and operational qualification (OQ) records obtained from the installer

or manufacturer; and other related material such as instrument

service and repair, warranty information, service contract conditions

and specifications.

iv Laboratory shall have operating instructions for each instrument,

including starting and shutting down the instrument.

v pH meter at least available two buffer to cover the range of pH

needed in the tests methods for determination of pH standards,

buffers available within their expire dates.

vi Probes of pH meter maintained with cap on and/or in buffer solution

or distilled water.

vii Biosafety cabinet shall have documented protocol and record of

decontamination and calibration (compl ied with ISO 15190 page 16).

viii Program established to check regularly the rate of airflow and particle

count in the Biohazard hoods or laminar flow cabinets (complied with

ISO 15190 page 16).

b The effectiveness of the autoclave operation shall checked monthly with a

biological indicator and thermal indicator.

c Thermometers and or thermocouples used for checking temperature of

incubators, water baths refrigerators, and freezers calibrated against a

reference thermometer by calibration laboratory and traceable to a national

standard.

d Automatic pipettes is there an initial verification of volume delivered

checked and calibrated routinely.

e There are regular checks to ensure that the equipments is performing

within the specifications.

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f Hygrometer shall calibrated by calibration laboratory and traceable to a

national standard, when humidity is influence to the outcome of the test.

g Equipment that is not operating properly is clearly marked to show that it is

out of service.

h When an instrument is discovered to be improperly operating, it is tagged

and taken out of service. Equipment is not returned to service until

performance checks and verification have been performed and

documented.

Each instrument has an established schedule specifying performance

checks, including the testing frequency and acceptable performance

specifications. These performance checks ensure the instrument is

operating properly and consistently prior to analysis.

All instruments required for the routine test in clinical microbiology field are

available:

Bunsen burners or other flame source functioning properly.

ii Colony counter for pour plate and spread plate method functioning

properly.

iii Incubators functioning properly, maintained within the specified

temperature range, temperatures monitored and recorded and spatial

variability in incubators checked periodically.

iv Water baths functioning properly, maintained within the specified

temperature range; temperatures monitored and recorded periodically.

v Working thermometers are traceable to national standards.

vi Microscopes covered with dust cover when not in use.

vii Optical surfaces of microscopes cleaned after each use.

viii Autoclave is functioning properly, monthly test of autoclave

performance using a spore strip or spore suspension of Bacillus

stearothermophilus, (that are capable of demonstrating a 6 log kill, of

Bacillus stearothermophilus).

ix Regularly scheduled maintenance program for each piece of

equipment, where appropriate and records of service where service

was required.

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x Distilled water that producing in-house and or purchasing from external

supplier and used to make media or reagents in clinical microbiology

tests shall check the conductivity periodically.

xi If total heavy metals may influenced the results of tests method for

specific clinical microbiology test, distilled water that producing in

house and or purchasing from external supplier and used to make

media or reagents in clinical microbiology tests shall be check the total

heavy metal periodically.

k Laboratory shall have arrangement for avoidance of cross-contamination

arising from equipment, such as:

Disposable equipment shall be clean and sterile.

ii Re-used glassware should be properly cleaned and sterilized.

iii Laboratories should have a separate autoclave for sterilization.

However, one autoclave is acceptable provided that adequate

precautions are taken to separate decontamination and sterilization

loads, and a documented cleaning programmed is in place to

address both the internal and external environment of the autoclave.

Laboratories should carry out initial verification of volumetric equipment

such as automatic dispensers, dispenser/diluters, mechanical hand

pipettes and disposable pipettes and then make regular checks to ensure

that the equipment is performing within the required specification.

m Verification should not be necessary for class A glassware which has been

certified to a specific tolerance.

n Equipment should be calibrated at least once a year for the accuracy of

the delivered volume against the set volume (for several different settings

in the case of variable volume instruments) and the precision of the repeat

deliveries should be measured.

o Where centrifuges are used in test procedures, an assessment should be

made of the criticality of the centrifugal force. Where it is critical, the

centrifuge will require calibration.

p Conductivity meters, pH meters and other similar instruments should be

verified regularly or before each use.

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6 REAGENTS AND REFERENCE CUL TURES

a Laboratory shall have sufficient & appropriate quantities of reagents /media

I commercial kits available to carry out the volume of work following the

required test methods.

b Raw materials (dehydrated formulations and individual constituents) shall

be stored under appropriate conditions, e.g. cool , dry and dark.

c All containers, especially those for dehydrated media, should be sealed

tightly and suitable for each material.

d Dehydrated media that are caked or cracked or show a color change

should not be used.

e Shelf life of prepared media under defined storage conditions shall be

determined and verified.

f Stored reagents, reference materials and supplies shall be under the

appropriate conditions and in a secure manner to ensure the separation of

incompatible materials.

g Solutions of reagent, standard and any other such as mobile phase

properly labeled with solution name, concentration , date of preparation,

expiration date, and identity of person who prepared.

h Disposed of reagents and standards solutions appropriately followed to

National and or local regulation.

Laboratory shall have documented verification or comparison of standards

and/or reference materials before use and the protocol when non

conforming results are encountered

Biochemical kit and rapid test manufacturers may specify control cultures

for use with their products. If not specified, quality control procedures for

biochemical tests and test media should include cultures that will

demonstrate pertinent characteristics of the product.

k Distilled or de-ionized water systems are monitored for conductivity,

bacterial content, and total chlorine periodically. Heavy metals analysis,

water quality test and use test are performed annually on the water

systems.

Reference cultures (stock cultures, lyophilized) are stored separately from

samples.

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'.iKAN KAN-TN-LM 02 Issue Number: 3 7 April 2016

m Media preparation and sterilization room are separated from work room to

prevent contamination.

n Laboratories shall ensure that all reagents including stock solutions, media,

di luents, and other suspending flu ids are adequately labeled to indicate, as

appropriate, identity, concentration , storage conditions, preparation date,

and validated expiry date and I or recommended storage periods.

o Reference cultures and reference material are required for establishing

acceptable performance of media including test kits, for validating methods

and for assessing I evaluating on-going performance.

Traceability is necessary, when establishing media performance for

test kit and method validations.

ii To demonstrate traceability, laboratories must use reference strains

of microorganisms obtained directly from a recognized national or

international collection , where these exist.

ii i Commercial derivatives of reference strains for which all relevant

properties have been shown by the laboratory to be equivalent at the

point of use may be used as alternatively.

iv Reference strains may be sub-cultured once to provide reference

stocks. Purity and biochemical checks should be made in parallel as

appropriate.

v It is recommended to store reference stocks in aliquots either deep

frozen or lyoph ilized.

vi Working cultures for routine use should be primary subcultures from

the reference stock. If reference stocks have been thawed, they must

not be re-frozen and re-used.

vii Working stocks should not be sub-cultured unless it is required and

defined by a standard method or laboratories can provide

documentary evidence that there has been no change in any relevant

property.

viii Working stocks shall not be sub-cultu red to replace reference stocks.

Commercial derivatives of reference strains may only be used as

working cultures.

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7 ASSURING THE QUALITY OF TEST RESULTS

a Laboratory quality control is an essential aspect of ensuring that data

released is fit for the purpose determined by the quality objectives.

b Approach of quality control is the principal recourse available for ensuring

that only qualified data is released.

c The principle of the laboratory quality control program is its internal quality

control to monitoring of analytical performance, and its external quality

control based on the laboratory's performance in proficiency testing

programs.

d Laboratory management is responsible for establishing a laboratory quality

control program and ensures that quality control is performed and reviewed

of quality control data for acceptability.

e Technicians are responsible for conducting quality control analyses in

accordance with the laboratory quality control program.

f Internal quality control is used to measure accuracy, contamination , and

matrix effects. The laboratory determines, where feasible, the accuracy of

all analyses performed.

g Accuracy and precision control charts are used to determine if the

measurement system process is in control and whether the results

generated by the measurement system are acceptable.

h Quality control program for media shall including:

pH of medium checked before autoclaving.

ii Positive control culture to reference culture performed per batch of

media.

iii Negative control culture to reference culture performed per batch of

media.

iv Checked of sterility per batch of media.

v Media that used for quantitative methods, quality control program

including compare positive control cultures on selective media and

non-selective media once per batch of media.

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BIBLIOGRAPHY

Centers for Disease Control and Prevention and National Institutes of

th Health) . BioSafety in Microbiological and Biomedical Laboratories4 ed.

U.S. Government Printing Office, Washington, D.C. 1999.

2 Usefulness of EC4 Essential Criteria for Quality Systems of Medical

Laboratories as Guideline to the ISO 15189 and ISO 17025 Documents,

Clin Chem Lab Med 2000; 38(10):1057-1064 © 2000 by Walter de

Gruyter.

3 Lennette EH, Balows A, Hausler WJ, Shadomy HJ. Manual of clinical

microbiology. Washington : Am. Soc. Microbial, 1985.

4 Eurochem/EA Guide 04/10. Accreditation for Microbiological Laboratories.

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