MICROBIOLOGY
are made at ward level to get the bottles to the laboratory within as short a time as possible should be matched with a laboratory focus to get the bottles on the instrument. The availability of automated blood culture instruments can enable any staff member along this pathway, clinical or laboratory based to positively impact this step by loading the blood cultures with minimal training so this KPI can be met without the need for the operation of a 24/7 laboratory.
n Blood fill volume
Monitoring and measuring blood fill volumes can sound like a tedious business, and it is. For bottles without a standardised protocol for determining volume, recording bottle barcodes and weighing them before they leave the laboratory and then when they come back is quite frankly beyond the capabilities of laboratories which have been stretched in terms of workload and staff shortages. The recommendations state that the optimum volume per adult patient is two sets totaling 40mL of blood so if this is to be measured and audited in any real way, laboratories will need to be sure that the data reflects how a hospital or trust is performing at a patient level and not generally across the pathway. This adds a layer of complexity to what data is actually required, as blood fill volume as they relate to the patient means a measurement of the volume of individual bottles as well as the number of bottles for the individual. Consistent over and underfilling bottles across the board could quite easily skew data to appear
like an optimum fill volume is being obtained. Similarly, one grossly overfilled set may give a volume equivalent to two optimally filled sets and so ideally bottle volume should be determined for each individual bottle.
Innovations in industry mean that there is availability of an automated instrument that can take the heavy lifting out of this task by assessing the blood fill volume of each individual adult bottle on loading to the instrument. Manual recording and manipulation of this data in programmes will be time consuming. Whether looking to industry or in-house for solutions to meet these standards, one should be satisfied that the data is easily exported in a manner that meets accreditation requirements, is easily understood and relayed back to NHS England if required and utilised within the hospital setting to guide any improvement initiatives. Having the information will only be of value if it is easily extracted, manipulated and acted upon.
Further challenges Ultimately, laboratories may be asked to audit KPIs relating to the blood culture pathway for processes that lie outside of their scope. This raises questions about when non-conformances are raised, how will they be recorded and with whom does the responsibility to resolve them lie? One thing seems certain is that without cross collaboration between laboratory and clinical teams, no real actionable insights and improvements can be made. Laboratory staff have always had a focus on patient outcomes and a ‘right result to the right patient at the
right time’ mentality, now they need to work with clinical teams such as sepsis and AMS committees, pharmacy and clinical skills, to ensure that the data they pull can reflect the needs of the hospital, direct resources where they are needed and help impact patient outcomes and antimicrobial stewardship in a positive way.
Microbiology has long been thought of as a ‘slower’ discipline. For so many years we could not compete with the rapid results of the blood sciences, with clinicians relying on C-reactive protein and full blood count results - returned in a fraction of the time compared to microbiological investigations - to inform treatment. We’ve come a long way in recent years. The introduction of newer and more advanced instrumentation and technologies has sped up microbiology in a way that could not have been foreseen 20 or even 15 years ago. A positive blood culture can now provide an identification and provisional anti- microbial sensitivity testing results in around six hours should the laboratory have access to the latest innovations and instruments available commercially. But as with all microbiological diagnostic tests, the importance of the pre-analytical stage cannot be underestimated and there also needs to be a focus on spreading the message across all functions within the hospital that blood cultures, when done correctly, take hours not days.
Conclusion
If laboratories do not adapt to meet the challenges these new guidelines bring, microbiology will continue to be perceived as the slow discipline where in reality there is a very real role to play in the pathway. This role, however, is dependent on outside factors for its success. Factors that will now be the responsibility of the laboratory to measure and audit, but not directly impact. And while there will inevitably be the need for discussions around resourcing, staffing levels and funding, there is opportunity here for small changes to have a big impact on patient outcomes, and for the laboratory to provide the data needed to continue to drive that change for the better.
References 1 NICE. Sepsis: recognition, diagnosis and
A positive blood culture can now provide an identification and provisional anti-microbial sensitivity testing results in around six hours should the laboratory have access to the latest innovations and instruments available commercially.
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early management. National Institute for Health and Care Excellence 2017 (https://
www.nice.org.uk/guidance/ng51/chapter/ Recommendations#managing-suspected- sepsis-outside-acute-hospital-settings)
2 UK Health Security Agency. UK Standards for Microbiology Investigation, S12 Sepsis
JUNE 2023
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