Thursday, August 11, 2011
Better Reporting for Microbiology Samples
In clinical microbiology we have the same three-phase cycle as everyone else: the pre-examination phase, the examination phase and the post-examination phase.
Microbiology samples have some unique characteristics that directly impact upon how we have to act in all three phases. Because many (hopefully not all!) samples contain contamination from surface flora, they have to have a very brief interval before being processed in the laboratory. Otherwise these contaminants overgrow and confuse the clinical interpretation of results. At the other end of the cycle, because our results tend to be wordy and qualitative, often they need to be associated with interpretive or explanatory or cautionary text. And that is sometimes a problem. In 1996 we published an article about reporting variation. Laboratories found 22 different ways to report the same quantity of bacteria in a urine sample. You can call that a lack of standardization in reporting structure.
In a recent customer survey, CMPT asked the information that we provide around our samples. Overall we found the responses quite elucidative and helpful. Some examples:
CMPT expectations for sample reporting, do not always agree with the policy and procedures of other institutions. It is sometimes difficult in knowing who is the best practice source.
The critiques should stick to the facts. There are many gray areas in Microbiology; many split opinions with no right or wrong answer.. The critiques often have the habit of stating these “gray” areas as clear cut, with the author’s opinion being presented as the only correct interpretation. It does not broaden anyone’s knowledge, by failing to represent the true dilemmas we face with cultures, and that there are no right or wrong answers in some situations.
I highlight these two results to make a few points. First, I understand the feeling of challenge about sorting out who is and who is not a practical source of information. I also disagree that with some consideration that the answer is difficult. Second, I agree that Microbiology opinion can suffer because of the “gray” areas.
In the olden days (like in the ‘50s and ‘60s and ‘70s) laboratorians were very comfortable with these gray areas because it meant that any answer was an OK answer. Laboratorians were free to report results any way that they saw fit. As I was told by a group of colleagues, "No one can infringe on my right to practice medicine the way I see fit".
The problem with that approach was that it was predicated on the notion that laboratories exist for the benefit of the laboratory and not for the clinician and not for the patient. Today the rules have changed and we understand that laboratory reports exist to provide information for the users. When patients are tested in multiple laboratories there is some obligation to at least ensure that the information that they receive has some level of consistency. Using the notion of “gray areas” as a justification for inconsistent reporting structure is not appropriate; something more definitive is expected.
In the absence of legislation and regulation or some other legally binding notion, at least we should make our decisions based on consensus within our community. It is called standardization.
And that is where PT/EQA committees can and do play an important role.
Take CMPT for example. Our committee is a group of 13 medical microbiologists, scientists, technologists, with both clinical and laboratory expertise. The group comes from across Canada and representing university hospitals, community hospitals and community laboratories. The group collectively perceives the wording of reports as important and spends considerable time coming to conclusions about mutually agreeable decisions about meaningful clinical reports.
If ever there is a group ideally designed to come to consensus opinion about the optimal way to report clinical samples, it would be a group just like this. CMPT is not the only PT/EQA program in Canada, nor is it the only one that has a committee that assesses reports and determines optimal reporting patterns.
So with respect to the two comments mentioned above, I have to respectfully disagree. There are better reports and poorer reports and there are community based PT/EQA committees well positioned to help define the better way to report.
Don’t agree? That’s OK. Submit an appeal with justifications. The committee also has the obligation to provide a second look.
But we will continue in our obligation to provide what we see is an important contribution to reporting standardization.
It is one of the things that we do.