Current trends in European microbiology

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1 Current trends in European microbiology Budapest, March 2010 Gunnar Kahlmeter Clinical microbiology Central Hospital Växjö, Sweden

2 The (R)evolution in medical microbiology Laboratory medicine in general and microbiology in particular is presently subject to rapid evolution. Do we know where we are going? What are the driving forces? Is it good, bad or just plain necessary? Who is gaining and who is losing?

3 Clinical/Medical microbiology is more than just a laboratory exercise. It is the analysis of a sample, the synthesis of results (of several samples) and the clinical consultation. Together these form the basis for - diagnosis, - therapy, - infection control - advice on and surveillance of antimicrobial resistance and several other Public health issues on a national and European level.

4 Clinical microbiology has many faces! Emphasis on Consultation Clinical work (regular consultation in the ward, on rounds). prescribes antibiotics and orders cultures. interferes directly in patient care. Emphasis on Analysis Laboratory work (methods, QC, accreditation, computer, stats ) consultation by telephone, committee work, education. interferes indirectly in patient care. Emphasis on High-throughput production a laboratory removed from the patient (and in some models the clinical microbiologist) and with no or very little consultation. outsourcing of one, several or all services does not interfere in patient care

5 The good news is UEMS accepted Medical Microbiology as a specialty in 2008 In seven European countries Clinical/Medical Microbiology is not a recognized specialty or subspecialty. Instead it is part of Polyvalent laboratory medicine : Belgium, France, Greece, Latvia, Lithuania, Portugal, Romania. Source: ESCMID Professional Affairs Query

6 Organisational change Consequences to be evaluated Quality of ordering and taking samples Acceptable dispersion of samples Transportation time and frequency of analysis Total laboratory throughput time (including timeliness of report) Array of competences Competence for performing analysis Competence for synthesis and evaluation of results Competence for clinical consultation Availability for consultation (staffing, working hours) Education and training Public health service - including infection control, HCAI (health care infections) and AMR (antimicrobial resistance). Recruitment of competent staff Cost

7 Trends in clinical microbiology the good, the tedious and the ugly. Concentration of resources Amalgamation of services Outsourcing of services Accreditation of laboratories Explosion of staff competences Automation of analysis Let us discuss these one by one

8 The good, the tedious and the ugly in microbiology (I) Concentration Trend: smaller laboratories abandoned or downscaled and all or part of services moved to bigger, central laboratories. Driving forces: to save money, to solve staffing and/or competence problems, to increase proficiency and diagnostic base and width, to afford investments. Negative consequences: consultant microbiologist lost to the hospital, infection control will potentially suffer, delays because of prolonged transportation of samples, throughput time increased, education in microbiology cease to be an entity.

9 The good, the tedious and the ugly in microbiology (II) Amalgamation Trend: the creation of large medical laboratory services where biochemistry, microbiology, pathology, cytology, genetics etc share facilities (and leadership). Often combined with concentration of services. Driving forces: To solve staffing/competence problems, to share leadership and staff (including highly specialised competences such as statisticians, computer scientists, epidemiologists), to afford 24h-services, defend investments (robots, computer systems). Negative consequences: unless microbiological leadership microbiology may suffer, consultant microbiologist lost to the hospital, infection control will potentially suffer, delays because of prolonged transportation of samples, throughput time increased, education in microbiology ceases to be an entity.

10 The good, the tedious and the ugly in microbiology (III) Outsourcing Trend: the selling out of microbiology (alone or as part of a total lab service) to big companies. - subcontracting a process to a third-party company. - the Model decision 1: special to outsource and low-volume is often tests made referred in the interest of lowering Model cost 2: ownership or making of local better laboratory use of transferred time and energy costs, Model 3: local laboratory abandoned, big company. redirecting or conserving energy directed at the transfers/divides samples elsewhere to private existing facilities. competencies of a particular business, or to make more efficient use of land, labor, capital, technology and resources. Driving forces: To consult external competence, to save money, to solve recruitment problems, to avoid having to invest (in competence, new buildings, machines etc). - Outsourcing became part of the business lexicon during the 1980s. Negative consequences: clinical advice and consultation at risk, consultant microbiologist lost to the hospital/area, overview lost, (Wikipedia) epidemiology (incl AMR surveillance) at risk, infection control at risk, education of staff at risk, delays because of prolonged transportation of samples.

11 Outsourcing Outsourcing is a time-worn common practice in most microbiological labs! To increase quality seek external expertise! To decrease cost avoid non-rational investments (competence, techniques, QC, etc) To pool low-volume requests.

12 Outsourcing microbiology The important questions are - why? - who is in command?

13 The good, the tedious and the ugly in microbiology (IV) Accreditation Trend: Compulsary accreditation of laboratory services. Driving force: Patient safety issues? Political. National harmonisation of services and quality? Negative consequencies: Streamlining (good and bad) Conserves practices (good and bad). Loss of freedom Costly. Too much focus on technical aspects? Carrot or punishment!!

14 The good, the tedious and the ugly in microbiology (V) An increasing array of competences Trend: increasing professional diversity

15 Evolution of competences in clinical microbiology Clinical/Medical microbiologist Biomedical technicians (lab.techs, 3 years) Secretary Janitor

16 Evolution of competences in clinical microbiology Clinical/Medical microbiologist Biomedical technicians (lab.techs, 3 years) Clinical scientists and MMMs (Medical Molecular Microbiologists) Computer scientist/technician Pharmacist Biochemist Epidemiologist Statistician

17 Is there a shortage of medically trained clinical/medical microbiologists in your country? Source: ESCMID Professional Affairs Questionnaire 16 Yes 8 No 2 No opinion

18 The good, the tedious and the ugly in microbiology (V) Explosion of competences Trend: increasing professional diversity Driving forces: the need for new competences, shortage of medically trained microbiologists, money. Negative consequencies: tends to conserve the shortage of medical staff, need for in-house (or external) training programmes in medical microbiology; Medico-legal issues to be solved

19 The good, the tedious and the ugly in microbiology (VI) Automation Trend: robots with high degree of autonomy, analytical width and capacity across specialty borders. Driving forces: saving labour; saving on competence(?), analysis by robot requires more general and less specific knowledge, shortened throughput time, 24h runtime, ergonomic. Negative consequencies: loss of knowhow, tempting to consider it too automatic, dangers when all use the same patented reagents.

20 Labs with CM Public health CM service Private Hospital based Private Independant Sum Pop million Labs per million Austria ,3 5,9 Belgium ,2 Bulgaria ,5 Croatia You can t read this 40 4,5 8,9 Czech Rep ,0 Estonia ,3 13,1 Finland ,3 4,7 France ,2 Greece ,3 Hungary ,5 Italy ,1 Latvia ,2 10,0 Lithuania ,5 4,9 Norway ,8 4,6 wait for the next slide! Russia ,6 Slovak Rep ,5 10,5 Slovenia ,5 Sweden ,9 The Netherlands ,4 UK ,6

21 Microbiological services in European countries (labs/million inhabitants) Sweden 3.9 The Netherlands 4.4 The UK 4.6 Norway 4.6 Finland 4.7 Lithuania 4.9 Italy 5.1 Austria 5.9 Croatia 8.9 Czech Republic 9.0 Estonia 13.1 Hungary 13.5 Belgium 17.2 France 69.2 Source: ESCMID Professional Affairs Questionnaire

22 Microbiology in the Netherlands The Inspectorate also concludes that the current position of medical microbiology in Dutch hospitals is necessary for patient safety and that outsourcing of these facilities is considered unacceptable. Bonten MJ. Ned Tijdschr Geneeskd Dec 6;152(49): Dutch.

23 Warning! The discussion around a coffee table in a clinical microbiology department should be about cases, diagnostics and grandchildren. Danger: when all discussions centre on workflow, throughput, logistics

24 Conclusions Microbiology is analysis, synthesis and consultation and is the basis for infection control in health care institutions and society. to break free the analysis jeopardizes synthesis, consultation and infection control. Outsourcing microbiology tends to dissociate analysis from synthesis and clinical consultation leaving clincal, infection control and public health adrift.

25 Conclusions (II) Amalgamation and concentration is necessary to a degree to preserve a reasonable basis for many modern diagnostic activities. Automation is good but requires a larger basis to be effective. There is a temptation to consider it too automatic and to prioritise skills in running the robot rather than the skills in the analysis itself. Accreditation is basically good but should extend beyond technical accreditation.

26 The future! Antimicrobial resistance development and health care associated infections will demand more of microbiology! The compromised host of today s medicine requires effecive antibiotics for profylaxis and/or treatment. Empiric therapy will fail increasingly often and its use needs to be minimised! - pre-emptive culturing - rapid diagnostics (detection + AST) - advice on antimicrobial mono- and combination therapy will require outstanding competence.

27 Shorten time to diagnosis Transportation of samples - distance, service, 24havailability of blood culture cabinets. Availability - opening hours (24 h service, 7 d). Analytical methods process time, random access Timeliness of reporting (and making sure reports are looked at) Shorten time to susceptibility test results Rapid detection of susceptibility Rapid exclusion of resistance

28 The way forward The true symbiosis between large, well equipped and richly staffed microbiological laboratories and smaller hospital based laboratories providing close-proximity microbiology and consultancy services and the basis for infection control. seems to me to be the way forward. /GK

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