Quote from IAPSM BEST PRACTICES COMPEDIUM
“Knowledge is of no value unless you put in to practice. Practice till you are the best, Practice to remain the best”
On 24th April, I had the opportunity to visit a Medical College in Dakshina Kannada. As hobby / passion / proactive social service, along with a post graduate from the department of Community Medicine, interacted with those who provide Mantoux test services in that College for mutual learning / capacity building to minimize programmatic errors if any. Current observations are attached with a few photos for illustrations.
In this institution pediatric age for TST is ≤16 yrs, adults are ≥17 yrs. Pediatric age group grossly varied 6 / 10 / 12 / 14 / 16 & 18 yrs in different Medical Colleges. Similarly number of PPD units for children are also varied from 2 to 5 TUs; volume varied from 0.025mL to 0.1mL.
We wish to share this with the global experts so that many who are senior consultants / policy makers in this field can advice / guide the service providers technically to minimize the errors to which the beneficiaries are subjected.
Another apprehension is that, if “we” are making these many errors in a simple skin test practiced for more than several decades, are “we” not making errors in the recent and more sophisticated procedures / investigations which may affect the treating doctors in decision making??
Kindly give very valuable input for strengthening the programme to eliminate TB by 2025 in India.
Following were the errors found earlier in various institutions.
1. Tuberculin vials were kept in the inner aspect of door of the domestic fridge, often abutting the freezer compartment, causing repeated thawing.
2. Vial brought to the nursing station / lab in the morning at about 9 AM and returned in the evening at about 5 PM. Till such time it is kept in a tray at room temperature.
3. Multi dose vial policy not adhered to; no opening date, no Beyond Useable Date & used for more than 2 months, even beyond 5 months till the last dose was spent.
4. Inadequate skill of ID administration, weal size not routinely measured hence if the diameter is <6mm, if placed Sub-Cutaneously, test was not repeated immediately.
5. Volume of the reagent varied from ~0.025ml to >0.1mL.
6. TU PPD-IP units - - 10 / 5 & 2 per 0.1mL, 50 doses per vial are available. In the absence of 5TU/2TU preparations, 0.05 or ~0.025 mL were drawn from 10TU PPD-IP per 0.1mL preparation and administered.
7. Yet times volume made up to 0.1mL by drawing normal saline and administered.
8. Confusion with regard to pediatric age:
9. Confusion with regard to PPD Units for children: 5 TU PPD-IP for all age group in some colleges and 2 TU PPD-IP or 0.05mL of 5 TU PPD-IP preparation being placed in a few other colleges.
10. No standardized documentation – entered in the general injection register in the OPD / general lab investigation register in the central lab etc hence, on request, >95% testing centers could not provide data when attempted through Google survey from, some could not share due to operational dilemma.
11. Results (reading) were not found entered in the case sheet in IP cases.
12. Loss to follow up: test administered but not read by one who prescribed the test and or by the tester as some were discharged before 48hrs of test / inadequate address.
13. As of now, no VVM on the vials in India.
With best regards
Holla n Team