All posts by michael

“The Requesting Pyramid”

In many laboratories, clinical details on request forms can be structured into a pyramid shape as below.

Let’s take the example of otitis externa.

A good proportion of request forms will be at the bottom of the pyramid, where there are no clinical details present to suggest that otitis externa is the clinical suspicion (as opposed to otitis media, cellulitis of the pinna, or some other condition). Also included in this category are cases where clinical details have been included but are unrelated to sample type, e.g. an ear swab sent with clinical details of “sore throat”. This scenario happens in all sample types with disturbing frequency… (e.g. mid-stream urine sent for a patient with clinical details of chest pain!)

The next level up in the pyramid is where clinical details are present but are insufficient to justify the sample being sent to the laboratory. For example the clinical details might state “Otitis externa“. However most patients with straightforward otitis externa do not need an ear swab sent to the laboratory. Laboratory culture of an ear swab in clinically suspected otitis externa should be the exception as opposed to the rule…

The top level of the pyramid is where clinical details are not only present, but they also give a sound rationale as to why the laboratory is receiving a sample. e.g. “Recalcitrant otitis externa not responding to topical treatment.” or “Diabetic with painful inner ear and fever, clinical suspicion of malignant otitis externa“.

This requesting pyramid applies to most different sample types and clinical scenarios.

At my laboratory, we are doing our utmost to turn this pyramid on it’s head. We have made significant progress to date. In fact our pyramid is starting to look more like a rectangle.

By the end of the year we hope to have removed the base of the pyramid altogether by adopting a policy of having accompanying clinical details pre-requisite for all microbiology tests. I.e. No clinical details, no test.

And that is the way it should be…

Michael

“The Addicted Microbiologist”

Up until recently I used to check my work emails on my I-phone every 20-30 minutes throughout the evening, sitting at home on the couch.

Not only evenings, but weekends and holidays as well. It was all a bit sad really.

It wasn’t for any particular reason, it was more like an automatic reflex. And if I went a prolonged period without checking them, I started to get a bit edgy and irritable…

I was addicted.

I have always had an addictive personality, and I have been addicted to many different things throughout my life. But I never thought I would be addicted to work emails however.

Wow, I am getting old…

So on realising I had a problem, I decided to do something about it.

About 6 months ago, I went cold turkey.

I didn’t just switch the work emails off from my smartphone, I completely uninstalled the server, so as to resist temptation.

So now when I leave the laboratory I don’t check my emails again until I am back in the laboratory.

And sure enough,  the sky hasn’t fallen. The emails sit there quite happily, waiting patiently for me to look at them. And when I do get round to looking at them the next (working) day, there is a little pile of them which I can then deal with somewhat ruthlessly, and certainly much quicker than answering them “individually” at periodic intervals.

Apart from addiction there is another good reason for not checking emails out of normal working hours. The majority of incoming emails are from people looking for something, a bit of your time, a bit of your expertise, a bit of your life…

Follow your own agenda, not other people’s.

March to the beat of your own drum…

I have five children, and a sixth on the way. I now have better things to do in the evening, like changing nappies!

But checking work emails at home is now a thing of a past. Trust me, there is not much that cannot wait in the world of microbiology…

Michael

“Communication Breakdown”

We conducted a brief audit recently on blood culture identification, and in particular how long it took for a definitive identification result (by MALDI-TOF) to be relayed to the hospital clinicians.

Audits are great at demonstrating that you are not half as good as you think you are…

Our audit showed that it was taking anywhere (depending on which cohort was studied) between 8 and 16 hours from when the identification was released by the laboratory into the “result repository”, until the result was actually viewed by a clinician.

And at the weekends the time delay was even longer, up to a day.

Oops…

You can have the most sophisticated equipment in your laboratory, and we do…

You can have highly skilled and motivated staff members, and sure enough, we have them.

And you can also have one of the most progressive provincial microbiology laboratories in the world, and I like to think we have that as well.

But it all counts for nothing if we can’t communicate our results in a timely fashion.

Audit can be painful to perform, but highly informative in implementing best practice.

So back to the drawing board for us. Time to sit down and talk with the clinicians and work out a way to communicate results more quickly in order to optimise patient outcomes.

It’s good to talk.

Pre-analytical, peri-analytical and post-analytical phases. They all matter, and they all need to be addressed…

Michael