The smaller your laboratory organisation is, the more often you will need to send samples outside of it. However most laboratories, regardless of size, will have to send some samples away to another organisation.
There are a few reasons why sending tests (“Sendaways”) to reference labs outwith your own lab organisation can be problematic:
- Longer turnaround time: The reference laboratory might only be a few hours away but courier timetables and the extra admin/registration required can sometimes add days to the result.
- Prioritisation: It can be difficult to get priority given to an important sample if it is getting sent outwith your own laboratory network.
- Different Laboratory Information Systems (LIS): This can lead to problems getting the necessary clinical information to the reference lab and also getting the result back on to your own LIS.
- Testing criteria: The criteria upon which the test is accepted or rejected by the reference laboratory are not necessarily criteria that you have had input into, and thus may not always be criteria you agree with.
All the above can be problems from time to time, but what I dislike most is the loss of control over the sample. If a complaint comes in from a clinician regarding processing of a sendaway sample, you often feel responsible for what happens to the sample from start to finish. However the reality is that you only have a limited amount of control over what happens to it when it leaves your laboratory. I admit I am a bit of a control freak when it comes to sendaway samples…..
I am fortunate in that the reference labs that my laboratory organisation uses are generally very good, but the key to having a good sendaway service is to have good personal relationships with the reference laboratories and the people who work in them. If this occurs, trust is built up between the labs, and the pain that control freaks like myself suffer when sending samples away is likely to be alleviated somewhat!
Here are a few rules I use when signing out results that contain Staphylococcus aureus… Some are ridiculously obvious but you will see where I am going with this.
- If MRSA, don’t report flucloxacillin as susceptible (!).
- If MRSA isolate from the hospital, ensure it has been sent to the reference lab for typing.
- Check Staph aureus isolates from other samples on the same patient have the same antibiogram.
- On sterile site cultures, release flucloxacillin only if susceptible.
- Do not report quinolones or tetracyclines in children or pregnancy.
- If the isolate is erythromycin resistant, check for a D zone before reporting clindamycin as susceptible.
- If the isolate is erythromycin susceptible and clindamycin resistant, double check everything before releasing.
- If it is a nasal swab, check that mupirocin and fusidic acid have been tested.
and there will be more that I haven’t thought of…
If you work in a microbiology lab, you will have a similar set of rules for Staphylococcus aureus, allowing for the inevitable place to place variation.
I “follow” these rules, subconsciously a lot of the time, on a daily basis. It does not take up a lot of time, but it is time nevertheless, and trust me, it is not the most exciting work.
The point I am trying to make here is that there is nothing in the list above that could not be programmed into a good LIS (Laboratory Information System) rules engine. Unfortunately when it comes to rules engines for microbiology results, our LIS is still a bit on the primitive side…..
As LIS systems become more advanced, so will the rules engines that they contain. I suspect that they will also become customisable in terms of being able to input easily the particular rules that you want.
So instead of Clinical Microbiologists and Senior Scientists sitting there wasting time following rules in our head we will more and more be able to get our computers to do it for us. And you can be sure that computers will do it a lot better than us, well me anyway..
All that will remain for us is to deal with the outliers or the exceptionally important (that is the way it should be), and that this aspect of our jobs will become redundant (hopefully we will not become redundant). We will generally not be signing results out, but simply making up the rules to allow computers to do it for us.
I have been thinking a lot about clinical details and urine samples, usually in the middle of the night, when sadly, I do most of my thinking.
So what are “acceptable” Clinical Details for urine samples coming into the laboratory?
Clinical details on urine samples can sometimes be basic, very basic… (all of these listed below can be seen written on request forms from urine samples. Such requests will come into most clinical microbiology laboratories worldwide on a regular basis)
- “Follow up urine post treatment, asymptomatic”
- “Positive dipstick”
- “Fatigue 6 months”
- “Smelly urine in catheter bag”
- “Chest pain”
- “Exclude infection”
- “Cloudy urine catheter bag”
- “Weight loss”
If clinical details were pre-requisite for urine samples, which of the above list would you consider as “appropriate”.
What clinical details one would regard as appropriate is always a little subjective in nature. Therefore my “acceptable” list might be different than yours…..
Insisting on (any) clinical details as a pre-requisite for testing is one thing, and is of course a start. Asking for appropriate clinical details takes the whole process to another level altogether….
It is a difficult area to navigate, but one that we should not avoid because of this.
If you were taking a tough line on what clinical details are appropriate to justify and optimise microbiology testing of the sample, none of the examples in the above list make it in my book…..