Tag Archives: quality

“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

“Time Out”

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We have been implementing some quite big processing changes in the microbiology laboratory recently with significant effects on users. Examples include making clinical details pre-requisite for selected sample types, and restrictions on the use of faecal occult blood (FOB) testing for symptomatic patients. The changes closely follow best practice guidelines, but  have proved unpopular with some people. Sometimes politics plays a part, for others it is the inconvenience of having to justify laboratory requests. Occasionally it is just a general reluctance to embrace change…

This confirms to me what I already knew, that you just cannot please everyone all of the time…

And nobody likes to be told what to do. I should understand that. I hate it more than most!

Sometimes in the past few weeks it has felt like that the world is against me. At these points it is definitely worthwhile taking a step back, reminding yourself of why the changes were implemented in the first place, and trying to gain as much peer support as possible.

I have also improved somewhat at convincing others of my point of view. This is something I have always been notoriously weak at. I have learnt that “face to face” meetings are undoubtedly best for this, emails are the worst, with telephone calls somewhere in between…

In short, you need to show people that you are human.

In trying to get things done and make progress, I have also been learning that there is a very delicate balance between “unilateralism” and trying to get consensus from everyone by collaboration. You will never get agreement from everyone, but there does need to be a “critical mass” of believers in order to carry and enforce policies.

There is little doubt that a couple of years ago, I would have buckled under the pressure, reversed the changes and gone back to my lab cubicle with my tail between my legs.

My skin has become a little thicker…

I have definitely learnt to see past the initial pain, and to visualise the long-term quality gains that have been made within the department, and for the clinical microbiology service as a whole.

These things take their toll however over the weeks and months… When working on such issues without a break, both the stress and exhaustion levels build slowly over time. The two terrible twins form a synergistic relationship.

But there is light at the end of the tunnel!

Next weekend I am going on a 5 week road trip with the family across the USA, from LA to NY.

It couldn’t have come at a better time… I can forget all about the microbiology laboratory for a while, the incessant phone calls and emails, the complaints, the politics, and the bureaucracy. I can concentrate on my life outside of the microbiology lab and recharge the batteries.

And hopefully when I get back I will still want to be here!

Michael

 

“The Road to Hell”

road to hell

“The road to Hell is paved with good intentions” (ancient proverb)

  • A laboratory might culture only 50 samples in a year for mycobacteria and look forward to getting a positive culture for Mycobacterium tuberculosis once in a ‘blue moon’.
  • A scientist might be happy to report “No microfilariae seen” on a blood sample despite having last seen a positive case of filariasis 25 years ago.
  • A clinical microbiologist might be willing to give advice on the significance of a rare filamentous fungus that they have only read about in the textbooks.

If I am doing a lab inspection/accreditation for another microbiology laboratory, one of the first things I do is find out is what tests/procedures are being done in low volume. (the other is to spend as much time as possible with the staff on the benches, to find out what really happens in the lab…)

We all have good intentions, but the cold reality is that if we only encounter something very occasionally, the chances of us getting it wrong are much increased.

Quality and knowing your/the lab’s limitations are necessarily entwined.

There is no shame in referring low volume tests on to another bigger laboratory, nor is there shame in seeking advice about something you don’t encounter very often, from someone who does.

I work in an affluent area of provincial New Zealand. Throw me into a microbiology laboratory in Sub-Saharan Africa and I would absolutely be a fish out of water.

Despite our best intentions, we can end up doing more harm to our patients if we think we are as good at doing the things we only do occasionally, as opposed to the things we do often… 

Michael