Tag Archives: microbiology funding

“Time Wasters”

If you work in a diagnostic microbiology laboratory, have a look at the list below to see if there is anything that sounds familiar in your workplace:

  • Performing susceptibilities on beta-haemolytic streptococci: Beta-haemolytic streptococci are invariably susceptible to penicillins, everywhere. If the patient has anaphylaxis to penicillin documented on the request form then fair enough. Otherwise, it is all a bit academic.
  • Culturing for anaerobes in areas of the body where anaerobes live (peri-anal area, vagina, oral, gastrointestinal): This is not very wise because if you manage to grow anaerobes from such sites then it may well represent normal colonising flora.
  • Susceptibility testing where topical antibiotics are the mainstay of treatment: Ear swabs and conjunctival swabs are the classic examples of these. It is well documented that in-vitro susceptibility testing correlates poorly with clinical response to topical antimicrobials, so why bother doing them in the first place?
  • Working up individual organisms where the culture plates clearly show”enteric flora”: For superficial swabs, this is a no-brainer. But even in sterile sites, the work up of each individual organism when they clearly represent enteric flora is of little clinical value. The classic example is culture of peritoneal fluid post perforation of the appendix.
  • Culturing sputum samples where there are lots of epithelial cells on microscopy: Because if you do so, you will simply be culturing a sample originating from the mouth or oropharynx, which will bear little relation to what is happening down in the lungs.
  • Culturing for bacteria in vaginal swabs: Vaginal flora contains lots of different colonising bacteria, most of which very rarely causes problems. It is probably only worthwhile looking for staphylococci and streptococci when there has been instrumentation or trauma (e.g. post-natal). The vast majority of vaginal swabs do not need cultured for bacteria.
  • Looking for bacterial vaginosis and yeasts in vaginal swabs where the patient has no symptoms: Vaginal swabs are sent to the laboratory for lots of different reasons. Often we do not get this reason, and when we do it is often not because the patient actually has physical symptoms. Looking for bacterial vaginosis and yeasts in the absence of clinical symptoms is rarely of any value.
  • Testing for Hepatitis A IgM where the liver enzymes are normal or only marginally elevated: Acute hepatitis A infection cause transaminases (ALT & AST) to increase into the hundreds and thousands. Testing for acute hepatitis A because the ALT is noted to be mildly elevated is not a useful exercise, and may cause more harm than good
  • Testing for Epstein Barr virus (EBV) infection when the patient already has positive VCA or EBNA IgG present: A lot of EBV requests come into the lab in patients who have already tested positive for EBV in the past. Symptomatic EBV reactivation in an immunocompetent patient is rare, if such a condition exists at all…
  • Performing a CSF viral PCR  in a patient after they have been discharged: The classic example is a patient who comes into hospital on a Friday with meningitic symptoms, and a CSF examination shows a lymphocytosis. As is often the case with so many molecular departments, the viral PCR will not be performed until Monday… At which point the patient could easily have recovered and be sitting at home or in the pub completely asymptomatic.

Not only are many of the examples above a waste of time, they are also a waste of both money and staff resources.

Furthermore, in many of the cases above, processing such samples may simply give misleading results and lead to inappropriate treatment.

This is only a list of 10. It would not take too much further thought to think of an additional list of 10. In fact the list could go on and on and on…

There are some ridiculously good new microbiology assays coming on to the market nowadays. Highly sensitive and specific PCR tests which can give highly accurate results back to the clinician in less than an hour. These are quite literally game-changers in terms of altering clinical management.

How can we afford to introduce these new modern assays? Only by looking at everything we do in the microbiology department, again and again and again, and assessing whether each test/process that we perform has clinical value.

Let’s not waste time, getting rid of the timewasters…

Michael

“Funding Microbiology tests in a World of Silos”

department_silos

You have been made aware of a new PCR test X. It seems to work very well, and diagnoses disease Y with high sensitivity and specificity, and with a decrease in turnaround time compared to what you have been doing previously. You are confident that it will decrease length of admission, reduce unnecessary investigations and will save your local hospital a lot of money.

It’s not even that expensive. Sure it costs more than your old style test but surely that will be compensated for by the above….

There are certainly plenty of Test Xs out there these days. A new one seems to come on the market every other week.

So why can it be so difficult to get funding for Test X?

A large part of the reason is that the savings made may occur in a different budget to the one where the extra costs are incurred, even if the central funder for both budgets is the same body. In other words the funding is siloed.

Funding silos are of course not unique to microbiology, laboratory medicine, or even healthcare. They are a ubiquitous problem, but can be frustrating nevertheless. And silos, as we are aware, are notoriously difficult to break down. They are much more of a problem with the system, rather than any individuals involved. Silos are the end result of society’s inability to look beyond the immediate environment and I believe they are culturally engrained in all of us.

If I knew of an easy way to break down the funding silos and get test x funded, I would divulge them, but I don’t think there are any easy solutions. Persistence is key, backing your argument up with as much evidence as possible, focusing on clinical risk, and extending empathy with your funder’s predicament are all good starting points, but does not guarantee success!

Michael

Silos of course do not just apply to funding but can even occur in departments in a laboratory! It is always worthwhile reviewing the good things that happen in your department and considering whether they can apply to other departments as well. Click here for a nice article on silos (about a 5 min read)