Tag Archives: result reporting

“Too much information”

The Art of Microbiology, ,

Can the microbiology lab give too much information to the clinicians?

Take the following hypothetical example regarding reporting of enteric type organisms:

Patient X presents with acute appendicitis with perforation. They are taken to theatre for appendicectomy and peritoneal washout, and started on IV cefuroxime and metronidazole. The sample of peritoneal fluid is returned from the microbiology lab as being “mixed enteric flora”. the patient recovers well, and they are discharged after 3 days on oral co-amoxiclav to complete a 1 week course of antibiotics.

Patient Y presents with acute appendicitis with perforation. They are taken to theatre for appendicectomy and peritoneal washout, and started on IV cefuroxime and metronidazole. However, in this patient, the microbiology lab decides to work up the individual organisms in the peritoneal fluid sample. The report states that the patient has grown an ESBL E.coli, an Enterococcus faecium, a Pseudomonas aeruginosa and a Candida albicans. Even though the patient is recovering well, the clinician feels obliged to cover the organisms that the micro lab has grown and reported, and changes the antibiotic therapy to meropenem, vancomycin and fluconazole. The patient unfortunately develops a bout of Clostridium difficile diarrhoea (!), extending their hospital stay by a week.

Microbiology labs can get very nervous about reporting “mixed enteric flora” from sterile site samples. They really shouldn’t be.

Here are a few pointers as to when it may be reasonable for the microbiology laboratory to report “mixed enteric flora”

  • Non-sterile site samples:- almost always
  • When several organism types are present- the number of different microorganism types present in a sample is inversely proportional to the value the lab can provide to the clinician
  • When no specific organism is dominant over the others
  • When source control has been achieved-this is important as in the hypothetical example above.
  • Drain samples- generally of low value unless the drain has just been inserted
  • When the clinical microbiologist has liaised with clinical team and clear that patient is doing well on current therapy- Treat the patient, not the result.

Such an approach saves the lab time and money, and may also be beneficial to the patient, as demonstrated above. Sometimes in our efforts to do the right thing, we end up trying just a bit too hard…

Michael

 

 

 

“Looking at the answer without knowing the question”

Future of Microbiology, ,

I remember as a junior doctor wading through piles (it was all paper in those days) of urine and wound swab results etc as part of my morning duties. Often the patient was not known to me, or due to the time taken for the result to come back I had forgotten what the reason was for ordering it in the first place. This makes interpretation very difficult. In essence you are to some extent managing the result, not the patient.

I am sure this still happens these days, and probably a lot more often than you would think.

The answer of course, is not only to make clinical details a pre-requisite on request forms (my mission to achieve this at my own labs is progressing slowly but surely) but also to present on the result whatever clinical details that were written on the original request form.

In this way the clinician can be reminded of the reason for requesting the test in the first place and can therefore interpret the result more accurately within the clinical context.

If clinical details are on a paper request form then it is time consuming to transcribe all these into the LIS, not to mention they may not always be legible. So I think there is an excuse for people/labs who currently use paper forms.

However once electronic requesting becomes established, there is no excuse….

CT scan results at my local hospital are reported in this fashion, always with the clinical details/reason for imaging at the start of the result report. Sadly, by looking at CT scan results, is often how I get some clinical details to help interpret microbiology results.

It is vital that the vision for microbiology follows along the same lines as CT reporting, presenting the clinical details as part of the result.

Michael