I had a good discussion with Gifford Batstone today about how microbiology will fit into the NLMC. It is very hard to standardise microbiology working and this leads to difficulty in setting standards and comparing labs. I suspect this is mainly because of a lack of clarity of clinical pathways that lead to testing, and uncertainty about the action that should follow a test. I'm not sure if these are possible to reconcile at anything other than a local level. This may be due to local differences in priorities (eg. Detecting multi resistant pathogens, or reducing drivers for antibiotic prescribing) and it may also reflect significant differences in interpretation of a very confused literature. We also give out mixed messages about the role of testing, with, for instance, the national SMI for wound swabs targeting a huge range of organisms, when clinical algorithms refer only to staphs and streps.
One way out of this mess maybe to build up order sets according to the target pathogens only and whether or not sensitivity results would be made available. This would leave labs free to decide exactly which pathogens they would look for, how they would do this in a way that supports the clinical pathway, and what they would do with the results. This would have to be linked to a clinical algorithm which would stipulate the entry into the testing pathway along with scripted actions that would happen with each result.
This is really no different to what we should be doing already. But because the entry into testing is so dirty we have lost sight of the purpose of the microbiology lab in supporting care. There is little point in sorting out testing if we can't take on the mess of the pre analytical pathway and take more responsibility for what happens on the other side of the lab.
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