I am not referring here to the Centre for Disease Control, which is a great resource which I use often to look up things I should know anyway, but don’t.

I am referring to the acronym “Clinical Details Culture”, an equally important CDC in my mind.

At the laboratory I work in, we have just implemented a mandatory clinical details policy for all microbiology samples. The only exceptions are those “difficult to obtain” samples taken from sterile site areas. For everything else, if there are no clinical details supporting the testing, then no testing is performed by the laboratory.

Now when I sign out a list of microbiology results I have clinical details on each and every request form. This is wonderful! In a good percentage of cases it changes both the testing and reporting of results. In other words the quality of results being produced has improved. And no longer will I get staff complaining to me that there are no clinical details on forms!

This has not been an easy policy to implement. Even after several months of preparation, there have been a few (almost inevitable) teething  problems which have had to be worked through. One key area is ensuring that all the staff members assess the clinical details provided in a consistent and standardised fashion. This has involved a lot of protocol development and these protocols are still in a process of evolution. For example “Erythema and increased pain leg ulcer” are acceptable details whilst “chronic leg wound” is not, and then there is the myriad of word variations in between. It is not straightforward!

Although most of the clinicians have been supportive of such a policy and indeed have embraced it by including excellent clinical details, there remains a small cohort who refuse to believe that the inclusion of clinical details on microbiology request forms is important. There are a few others that believe in the policy in principle but have concerns over the logistics.

The goal over the next year or so will be to continue to build a clinical details culture amongst clinicians so that clinical information on microbiology forms (and all laboratory request forms) is the expected norm. This represents a positive step for all the involved stakeholders; clinicians, laboratory staff and patients alike.

Along the same lines I hope that many other diagnostic microbiology laboratories both nationally and internationally adopt a similar stance. The presence of clinical details is a key element of effective diagnostic stewardship. Without them, you are already on a hiding to nothing…

Michael

We all like to have a bit of a grumble when a request form has no clinical details on it. I assume it must make us feel a bit better. It is also incredibly frustrating.

Clinical details are important and paticularly for microbiological requests for several reasons. As well as giving clinical justification to the test order, clinical details allow us to decide what tests to perform, what media to put up, how long to incubate the sample for. They are also important for determining the clinical significance of any isolates or results. It allows us to decide what antibiotic  susceptibilities are required to be tested and reported, and so on. In other words, clinical details for microbiology tests are very important.

Clinical details do not have to be an essay. A couple of lines usually suffices, which should include the clinical rationale for testing, current treatment, any allergies, and a mention of travel, pregnancy, animal contact etc etc where necessary.

Traditionally, the laboratory worked very much in isolation from the clinical aspect of patient care. Samples were received, and processed indiscriminately regardless of cost, quality of specimen, reason for testing, how long the sample took to arrive at the lab etc. Things have moved on from this and the lab is slowly becoming more pro-active and involved in which specimens should be tested, and when they should be rejected. However, despite this, the provision of brief but pertinent clinical details remains stubbornly low. 

Old habits die hard…

There are some potential reasons why lab users may not include clinical details:

• The requestor may not believe that the inclusion of clinical details will make a clinical difference and therefore may not feel the need to include them.
• The time used to include clinical details on the request form could be used for something else.
• The clinical reasons for testing may not meet standard testing or funding criteria for the test so the requestor may not wish to disclose them.

However the main reason that so many request forms come with no clinical details included, is because we allow it to happen. We might grumble, but in the vast majority of labs, we go on to perform the test, because if we didn’t we could potentially cause harm to the patient….

But in contrast, and paradoxically, best quality patient care requires the provision of clinical details to the laboratory.

In fact, they are so important, that we should really insist on them….

If you made clinical details mandatory on a request form, then non-critical samples with no clinical details could be reported with a comment to the effect that the sample will be stored but not tested until appropriate clinical details are included (sterile site samples and blood cultures would be the exceptions here).

If such a policy were implemented, then I think you would find that the percentage of forms arriving with appropriate clinical details would increase dramatically, and quickly.

It is just getting there that is the difficult bit.

The major problem is in the implementation. Communicating to all lab users about major changes can be difficult, and dealing with the inevitable queries if samples are rejected can be time consuming. There may also be a proportion of lab users who may just simply dislike the fact that they have to include clinical details in order to get the test performed.

I think that in the future all clinical microbiology labs will insist on the provision of clinical details in order for testing to take place, much in the same way that most radiology departments now insist on clinical details before the patient is imaged.

When electronic request forms become more commonplace, I think it should alleviate this problem to a certain extent. An electronic system can be set up in order to not allow the request to be completed without the provision of appropriate clinical details.

The road to best practice and the changing of current habits can be a long and painful one. Maybe we need to develop a thicker skin, keep communicating, keep justifying our reasoning, and just get on with it!

Michael