Tag Archives: gatekeeping

“The devil is in the (clinical) details”

Lack of clinical details on the request forms must affect thousands of microbiology laboratories worldwide.

"Very high temperature, query cause?"
“Very high temperature, query cause?”

Clinical details are important for the following reasons along with a few examples, of which there are many more:

  • In deciding what different tests to carry out on the sample. Particularly important in enteric samples, where travel history and duration of symptoms can lead to more efficient testing.
  • In deciding what antimicrobial susceptibilities to report. For example if the patient is pregnant, has a history of antibiotic allergy, has a history of an MDRO etc.
  • It also ensures that the requestor has thought about why he/she is ordering the test. If the requestor understands why they are ordering the test, it is likely to make inappropriate ordering less likely in the future.

As mentioned before, I think the introduction of electronic ordering will alleviate this problem to some extent. With electronic ordering one can simply prevent the request being completed unless some clinical details are submitted.

Laboratories have traditionally taken a very passive approach to this problem, processing everything that arrives at reception. I think this will change with time, as laboratories gradually become their own gatekeepers and the technologies to facilitate this come into play.

I would love to one day be part of a laboratory set-up where short but pertinent clinical details are mandatory on the request form for a microbiological sample.

I would not be looking for an essay, just a rationale for the test and any other pertinent clinical details as necessary….

I am interested in whether anyone else makes clinical details mandatory for microbiology samples, and what their experiences are of this?


p.s. You may be interested in this website on pharmaceutical microbiology. http://www.pharmamicroresources.com/

“All samples are equal but some are more equal than others…”

Most samples that arrive into the microbiology laboratory are processed. However there are some where the clinical usefulness of the result must be almost negligible.

Let me give you a few examples…

Swabs of boils that have just been lanced. It is the lancing (draining of pus) which will almost certainly lead to the infection being cured. Much the same applies for peri-anal abscesses.

Swabs of chronic ulcers, including pressure sores. These will almost certainly be colonised by bacteria. Even if a “pathogenic” organism is isolated, it is impossible to say what it means in this setting.

Culturing drain fluids from drainage bags where the drain has been in for more than 5 days. Whatever bacteria are growing in the drainage bag will bear little relation what is growing in the collection that the fluid has come from.

Swabs from ears where the history is of a straightforward otitis externa. Outer ear canals grow all sorts of junk which rarely means much in this clinical setting.

Samples from long term urinary catheters where urine has become cloudy or smelly. This demonstrates that urine has become colonised with bacteria which will always happen eventually when a catheter is in situ. Usually an indication to change the catheter.

Follow up urines after a urinary tract infection has been treated. Rarely indicated, except in pregnancy, pre-urological surgery and in transplant patients. Treat the patient, not the laboratory result.

and the list goes on….

I suspect samples from the above list make up a good 20% of the daily workload of a microbiology laboratory.

But how do you police it?

Not easily. Probably needs a combination of the following:

  • Education of Laboratory Users: Grand Rounds, Clinical Updates etc etc
  • Feedback in the form of a comment added to the test report where the test looks to be unjustified.
  • An insistence on clinical details supporting a rationale for the test.

Regarding the last point, I think the establishment of electronic ordering, which is now starting to come into many labs, may facilitate this, effectively making it impossible to complete test ordering without a supporting clinical rationale for the test.

We process most microbiology samples that come into the lab because it has always been done this way. However with the health budget becoming ever tighter, it is time for the laboratory to move from being the passive recipient and start becoming the gatekeeper for what should be done and what should not.

Think how much time it would free up with at least 20% of the workload gone, and also with the knowledge that the vast majority of specimens that you were working on were genuinely important….


On another topic altogether, click here for an interesting article on looking for anti-microbial substances on the seabed, a good place to look in my opinion.