Diagnostics
Vancomycin-resistant Enterococcus (VRE); and discontinuation of antibiotics and safe discharge of a baby (found not to have sepsis). The full details of these success stories can be viewed in Figs 5-7. “We are really excited about how this has
impacted our patients’ lives,” she commented. With regards to the patient identified as having an invasive Strep A infection, Olubunmi also pointed out that this: “didn’t just help to improve the outcome for the patient but also helped to protect their loved ones.”
Summary In summary, BioFire technology transformed diagnosis and management of sepsis at the Royal Berkshire NHS Foundation Trust. The pre- analytical stage of the process was optimised in terms of blood collection, compliance with the four-hour standard, and ensuring the integrity of the sample. In terms of the analytical stage of the process, the Trust saved significant amounts of time – a minimum of 17 hours and, in some instances, even more. The post-analytical stage of the process requires further optimisation and the Trust is currently working on automatic data transfer of the results, which will make the process even quicker. Olubunmi pointed out that early pathogen identification facilitates early multi-disciplinary team (MDT) conversations around: l Therapy (microbiologists/clinicians) l Source control (surgeons/IR) l Investigations (Echo/radiologists) l Infection prevention and control (IPC) and antimicrobial stewardship (bed management/tracing/isolation)
l Giving confidence to ambulate (virtual ward).
“When a patient comes through ED, we use Sepsis Six, take two sets of blood cultures, put them on empirical antibiotics, put them in AMU, and carry out effective, targeted treatment in 6-8 hours. Then, from AMU, they can go back to their care home or their own home. It is very multidisciplinary and involves microbiologists working very collaboratively with the medical team,” Olubunmi explained. “We have rarely had to bring patients back in. The key has been getting a result right there and then, saving the patient from having to go to elderly care – we know that, when they are moved there, it can lead to an increased risk of deterioration. “We presented our findings to the Board and
they have approved the funding, so this is now ‘business as usual’ for us. This is saving patients’ lives and it is improving patient flow and discharges. We have achieved this by following our Trust’s values: by being compassionate, being aspirational, and being earlier adopters of
Fig 4. Antibiotics decision following BioFire results Date 09.07.23 Event
Severe sepsis from septic arthritis of left knee joint: immunocompromised due to Alpha-1 antitrypsin deficiency (an inherited disorder that may cause lung disease and liver disease). Unwell for 3 weeks, sore throat, thigh cellulitis, swollen elbow. Acutely unwell for 2-3 days (nausea, drowsy, shivers, swelling of left knee, not responding to Co-Amox. Two sets of blood cultures and knee aspirate sent to lab. Blind Abx treatment with IV Flucloxacillin +IV Clindamycin; joint washout for source control of sepsis. Remained critically ill in septic shock; transferred to ICU.
10.07.23
Blood cultures flagged positive, BioFire identified Group A Strep. Targeted antibiotics started within 10 hours of admission; IV immunoglobulin started for confirmed case of invasive Group A Strep; UKHSA notified for tracing close family and institution of antibiotic prophylaxis. Patient clinically stable in ICU.
BioFire identification within 9 hours and 30 mins (1hr of delay in scanning result on EPR). MALDI-ToF identification within 15 hours 30 mins (6 hours later than BioFire identification).
Fig 5. Group A Strep case; 44-year-old male, brought in by ambulance in ED. Date
30.01.22 30.01.22 31.01.22 31.01.22
Time 11.10
12.09 05.11 06.10
Event
Blood culture collected from PICC line Blood loaded onto blood culture incubator Sample bottle flagged positive
BioFire – Enteroccocus Faecium AND detected marker of resistance to an antibiotic group (VRE) Antibiotic changes – IV meropenem stopped; VRE targeted antibiotic commenced – linezolid Source of infection identified – perianal abscess
31.01.22 16.08
Conventional result became available – matches BioFire but resistance/sensitivities of antibiotics not available until 02.02.22
Fig 6. VRE case - 58-year-old male, with leukaemia, fever, and neutrophils 0.0.
technology. It took hard work in convincing our multidisciplinary team and the executive team, writing reports and getting the data, but if we put the effort in and the get the right people on board, we can adopt technology earlier,” Olubunmi continued. She urged the audience not to wait for NHS England to instruct them to adopt innovative technology: “We can do this locally and share our experiences and knowledge
with others. Oxford are now sending their doctors to us to see what we are doing. NHS Improvement are also visiting us to see what we are doing. Technology implementation works better ‘bottom up’ rather than ‘top down’ – you get better buy-in this way,” she commented.
Next steps The next steps are to implement IT for result
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