Department of Medical Microbiology

DEPARTMENT OF MEDICAL MICROBIOLOGY AND PARASITOLOGY NATIONAL HOSPITAL ABUJA

QUALITY OF CARE POLICY AND OPERATIONAL GUIDELINES

NHA/CD/QOCP/MEM/001

Dr. SONIBARE.S.A.

HEAD OF DEPARTMENT

INTRODUCTION

Medical microbiology is a clinical laboratory department providing diagnostic, therapeutic, clinical, consultation, training and other supportive services in infectious diseases and related conditions.

It started as a unit of the hospital’s combined pathology departments (Chemical Pathology, Haematology, Histopathology and Medical Microbiology) and by 2002 had developed into an independent specialised department with its own sub-specialities and units.

The department is fully accredited for residency training by the West African College of Physicians (WACP) and National Postgraduate Medical College of Nigeria (NPMCN).

The department is actively involved in training of resident doctors and other postgraduate medical officers, house officers, medical laboratory scientist interns, corps members as well as students on industrial attachment. It also conducts research in infectious diseases and related fields.

1.1 Vision Statement

To be the preferred provider of customized laboratory, clinical and research services which offer clients the highest quality of service and responsiveness with the latest cutting edge technology in microbiology diagnostics and prognostics.

1.2 Mission Statement

Our goal is to enhance the Nigerian healthcare system by providing the highest quality of medical laboratory services to physicians and patients.

2.0 QUALITY ASSURANCE POLICY

The Department of Medical Microbiology, National Hospital, Abuja in line with the mission and vision of the hospital is committed to the delivering high quality clinical and laboratory services in the areas of infectious disease diagnostics as well as infection prevention and control. Our minimal standards are based on International and National standards including the ISO 15189 as well as other regulatory standards and requirements.

training and retraining of our staff and regular servicing of all our equipment as required
reviewing our standard operating procedures (SOPs)
adequate record keeping
regular calibration and re-calibration of our equipment
ensuring work place safety
internal and external quality control and assurance
reduction in turnaround-time (TAT)
frequent client feedbacks by customer satisfaction survey

3.0 STRENGTH OF THE DEPARTMENT

The department has well trained personnel who utilise up to date processes and procedures to carry out testing on human and environmental specimens using modern equipment in line with best international practices. In addition, our clinical and support staff provide both clinical and consultation services as well as public health support in a timely and efficient manner.

The department has a multidisciplinary medical and allied health team which includes health care professionals in Pathology/Laboratory Medicine, Nursing, Medical Laboratory Science and other related specialties working in synergy to ensure quality.

The Head of Department is a Consultant Medical Microbiologist, a medical doctor who holds a postgraduate fellowship of the WACP, NPMCN or its equivalent. Other staff are Consultant Medical Microbiologists, Resident Doctors in Medical Microbiology, Infection Control Nurses, Medical Laboratory Scientists, Medical Laboratory Technologists, Medical Laboratory Assistants, Scientific Officers and Administrative Officers.

Specialized services offered by the department include:

Diagnostic/Laboratory services

Clinical Bacteriology
Microscopy, culture and susceptibility of clinical specimens (blood, CSF, stool, sputum, swabs, aspirates, semen)
Isolate identification and susceptibility testing

Mycology
Fungal studies of body tissues and fluids: skin, hair, nails, aspirates

Virology
Detection of serological status: HIV, Hepatitis B and C, HSV
HBV 5-Panel testing
Viral load estimation: HIV, HBV, HCV

Parasitology
Detection of parasites in blood, stool and urine

Molecular
PCR testing (COVID-19, GeneXpert)

Immunology
Antigen and antibody detection: H. pylori ,TORCHES, COVID-19 RDT testing

Clinical services

Routine STD clinic at the Special Treatment Clinic.
Consultation services on infections
Results verification and reporting for Medical Microbiology investigations.

Training

Training of medical microbiology resident doctors, residents from other medical specialties and medical students.
Provision of internship training for medical laboratory scientists.
Provision of in-training industrial attachment for microbiology and related undergraduate courses.

Research

Initiating and conducting research in clinical microbiology and related areas.
Providing support for clinicians and other researchers.
Coordinating the institution’s research collaboration in medical microbiology and related areas.
Conduct peer-reviewed research to meet the key priorities of the department and clients.

Infection Control

– Detect, prevent and control infections within the hospital.

– Sustain service orientation, education and compliance for all staff in infection prevention.

Antimicrobial resistance surveillance/Antimicrobial stewardship

Monitor changes in populations of microbes to help understand evolving patterns of resistance to antimicrobials.
Encourage and monitor the rational use of antimicrobials in the hospital.

Diagnostic Stewardship

Provide timely and value-added professional consultation to clinicians and other health professionals.

4.0 OPERATIONAL GUIDELINES

Hours of Operation; the department operates on a 24-hour basis everyday regardless of public holidays & weekends.

Call hours (Emergency Specimens Only) – 4:00pm-8:00am Monday to Friday and 24 hrs on public holidays & weekends.

Diagnostic/Laboratory

All laboratory requests must be made on the National Hospital request platform and reports can only be assessed on the same platform in line with laid down guidelines.
n/b external patients are permitted to walk into the Medical Microbiology reception with their request forms.
Only specimens that meet the departmental guidelines will be accepted and processed.
All test results, having undergone required quality checks are reported in authorized format using the Laboratory Information System (LIS), by the Consultant Medical Microbiologist or his designee.

Clinics/Consults

• The department provides clinical services during routine hours and consultancy services at all hours.

• Patients are seen by referral from other clinic or units within the hospital.

• Patients are referred to other clinics for specialized care and are referred to other centres on request.

• Clinical consults are accepted from consultants in charge of other departments or units with proper documentation and involve a personal review of the patient.

Sexually transmitted infections clinic

This clinic deals with other sexually transmitted infections not due to HIV.

Special Treatment Clinic (STC)

This clinic primarily handles cases of sexually transmitted viral diseases, with emphasis on patients infected with the Human Immunodeficiency Virus (HIV).

Consults

The department receives consults at all hours of the day from other departments.

5.0 WEEKLY ACTIVITIES

6.0 ORGANISATIONAL CHART OF THE DEPARTMENT

7.0 HEALTH AND SAFETY POLICY

Our policy is based on the National policy on injection safety and healthcare waste management to ensure a safe working environment with minimal risk to our staff, visitors and clients. .

Responsibility:

all laboratory and clinical staff
all visitors to the department
all clients of the department

Key elements:

Implement Healthcare waste management practices to ensure proper waste segregation and disposal in the department.
All departmental staff are to be trained in infection prevention and control including laboratory safety.
All staff must comply with basic and specialised safety precautions dependent of activity and job description.
Only authorised personnel are allowed beyond the reception within the medical microbiology laboratory.
Personnel should not eat or drink in the laboratory and should avoid any activity that introduces objects into the mouth.
Personnel must comply with standard microbiological safety practice.
Processing of specimen must adhere to the appropriate biosafety level.
Disinfection and sterilization must be applied as laid down in standard microbiologic practice.
Only research authorised by the hospital and the departmental management will be accommodated within the clinics and laboratory.

8.0 MINIMUM STANDARDS POLICY

The department will maintain and implement a policy of quality diagnostic and clinical services in infectious diseases by ensuring our staff well-trained, committed and accountable and work procedures are continuously updated in line with international best practices.

9.0 LIST OF STAFF AND QUALIFICATIONS