The Impact of Consolidating Microbiology Services

The Impact of Consolidating Microbiology Services: The Birmingham Experience

Abstract

Laboratory medicine contributes to many clinical decisions by providing clinicians with essential information for the prevention, diagnosis, treatment and management of disease, making pathology services an integral part of the healthcare system. However, as a result of financial and public health demands, there has been extensive consolidation of pathology laboratories. A recent merger between two Trusts in Birmingham, Birmingham Women’s Healthcare NHS Foundation Trust (BW) and Birmingham Children’s Hospital NHS Foundation Trust (BC), has led to the consolidation of microbiology services. The main aim of this paper is to describe the impact of such consolidation, focusing on patient care. Turnaround times pre and post-consolidation were compared to evaluate the efficiency of the consolidated services. A secondary aim is to describe the impact on pathology staff and some of the problems associated with the consolidation process. Input was obtained from pathology staff, management and service users through the use of questionnaires and interviews to discern the quality of the microbiology service pre and post- consolidation. It was found that consolidated microbiology services at Birmingham Women’s and Children’s NHS Foundation Trust (BWC) have enhanced the quality of patient care through efficient reporting of results. A financial saving has also been achieved through loss of personnel and elimination of duplicated tests and equipment. The response to the consolidation process from service users and pathology staff was ambivalent. Consolidation at BWC has had success but further analysis is required to evaluate the long-term impact of pathology consolidation on patient care and cost savings.

Introduction

Pathology services consist of the main disciplines haematology and blood transfusion, clinical biochemistry, microbiology and histopathology. A microbiology laboratory is essential in the diagnosis of infectious disease, detection of antimicrobial resistance, containment of outbreaks and even potential bioterrorism events [1-6]. In February 2017 BW and BC merged to create BWC, the first specialist NHS Trust in the United Kingdom (UK), dedicated to the care of women, children and families from across the West Midlands region and beyond. Microbiology services at BW and BC provided an analytical and interpretive service on a range of clinical specimens. Prior to the Trusts merging, both microbiology laboratories had close links despite being around five miles apart. The out of hours service for both laboratories was provided at BC and supported by BC staff only. Microbiology consultants and infection prevention and control staff already worked at both sites and in addition to this, some specimens generated at BW such as antibiotic assays and Chlamydia/Gonorrhoea PCR were performed at BC.

The key purpose of consolidating pathology services was to increase efficiency and minimise operational cost [5, 7, 8, 9] by providing one laboratory with extended hours and an expanded testing repertoire [10]. The consolidation of microbiology services at BW and BC on to a single site was in response to both national and local needs and took place in November 2018. Nationally, the Pathology Modernisation and Integration agenda aims to improve quality, cost effectiveness and standardisation, with a view to modernising pathology services [6]. Locally, the priority is to focus on the long-term arrangement of pathology services in Birmingham and Solihull (BSOL) as a part of the BSOL Sustainability and Transformation Partnership. Through developing a new workforce model, an efficient microbiology service was anticipated at BWC, implementing quality improvements as well delivering a minimum of 10% financial savings [6, 9, 11].

The aim of this study is to evaluate the consolidation on its success in improving quality of patient care. Research suggests that consolidation of pathology services can lead to cost savings whilst improving the quality of service [5, 7, 9, 12]. But, it can also lead to job losses, increased turnaround times (TATs) and dissatisfaction amongst pathology staff and service users [13]. The outcome of this project will be of value to this Trust as well as others in a similar position providing them with a model for laboratory consolidation.

Materials and Methods

Settings:

BW, located in Edgbaston, provides specialist healthcare services covering gynaecology, obstetrics, neonatology and andrology. Microbiology at BW handled approximately 80,000 patient specimen requests prior to consolidation with a test repertoire including blood cultures, genital specimens, cerebrospinal fluids (CSFs), admission swabs, antenatal bloods, urines, milk bank cultures, post mortem specimens, environmental specimens, routine specimens (e.g. wound and eye swabs), mycoplasma/ureaplasma specimens and cross infection specimens for methicillin-resistant Staphylococcus aureus (MRSA) screening and rectal swabs for detection of extended spectrum beta lactamases (ESBL), gentamicin resistant organisms and carbapenemase-producing Enterobacteriaceae (CPE) [14]. Specimens were collected by the Trust Porters throughout the day (08:30, 10:30, 12.30, 15:30 and 16:30) with specimen reception staff undertaking collections at 11:30 and 14:30. Specimens were also transported directly to specimen reception via the pneumatic tube system and by clinical staff. Printed reports of results were provided for all requests, with reports being distributed twice daily (at approximately 12:30 and 18:00). There was also electronic access to results via the results web browser. Unusual or important results, including all positive blood cultures, were routinely telephoned by the laboratory to the requesting clinician as soon as they were available [1]. The laboratory was staffed with bands 8 (1), 7 (1), 6 (1), 5 (1), 4(1), 3 (1) plus a band 2 in specimen reception for data entry. Pathology staff, depending on their role and level of responsibility, is placed at Agenda for Change pay bands starting from band 2 up to 9. The opening hours of the department are stated in Table 1.

BC is a city centre- based, leading UK specialist paediatric centre serving 90,000 children and young people annually [14]. Prior to consolidation the BC microbiology service was processing over 100,000 specimens per annum [14]. Its test repertoire included blood cultures, sterile fluids, cross infection specimens, urines, respiratory tract specimens, stool culture and Clostridium difficile testing. An extensive virology service was also provided. Internally, specimens were collected in a similar manner to BW. Specimens from BW were received daily via a courier. Reports were distributed to wards electronically via the Integrated Clinical Environment (ICE) system, the electronic requesting and results reporting system designed to operate within primary and secondary care. It can be integrated with any laboratory information management system (LIMS) as well as GP systems. Although the department had made some progression towards going paperless, some wards still required hard copies (e.g. outpatients). Telephoned results were comparable to BW. The laboratory was staffed with bands 8 (3), 7 (1), 6 (6), 5 (1), 3 (5).

The consolidated microbiology service located on the BC site provides tests in bacteriology, molecular biology, mycology and virology, covering the test repertoire and workload of both BW and BC. Internally, specimens are still collected the same way. However specimens from BW are packaged in specimen reception and sent via a courier to BC at set times through the day (04:00, 06:30, 10:00, 14:00, 17:30, 20:00, and 23:59). The reporting of results remains the same as it was at BC prior to consolidation.

Table 1. Opening hours of the Microbiology service provided at BW and BC prior to consolidation and the opening hours of the consolidated Microbiology service at BWC.

	Microbiology service at BW pre-consolidation	Microbiology service at BC pre-consolidation	Microbiology service at BWC post-consolidation
Weekdays (Monday to Friday)	09:00-17:30	09:00-17:24	08:30-20:00 (core hours until 17:00)
Weekends	08:30-12:30 (Saturdays only)	09:00-17:24	09:00-17:30
Bank holidays (except Christmas Day)	09:00-12:00	09:00-17:24	09:00-17:30
On-call	At all other times, provided from the microbiology department at BC	At all other times	At all other times

Questionnaire design:

Questionnaires were designed to gain feedback from service users and pathology staff to determine the impact of consolidation. Closed questions using the Likert scale was used so respondents could indicate how strongly they agreed or disagreed with statements. These were deemed quicker for respondents to answer as well as being easier to analyse. Open questions were also included to allow respondents to express their opinions and allow a greater insight (see Appendix 1).

Pilot studies were performed on a smaller sample size to test questionnaires prior to using them to collect data. This was to ensure the questionnaires were appropriate in fulfilling the purpose of the study, the questions and instructions in the covering letter were easy to understand, the format of the questionnaire was suitable and to evaluate the length of the questionnaires. All feedback was taken into consideration and amendments made before distributing the final questionnaires.

Data collection:

Online questionnaires were disseminated to BW microbiology service users (Appendix 1a) prior to consolidation to ascertain the quality of the current microbiology service and their view regarding the consolidation. All BW based staff were invited to complete the questionnaire. This was done by liaising with the Communications team at BW and distributing the questionnaire’s website link on the Trust’s Intranet page which all service users had access to. This was deemed the best method to reach as many people as possible as it would have been difficult to obtain contact details of all service users.

Questionnaires were sent to pathology staff of microbiology departments at BW and BC prior to consolidation (Appendix 1b) and to pathology staff of the microbiology department at BWC six months after consolidation (Appendix 1c) to assess the impact on pathology staff.

Unstructured interviews took place with the BC Laboratory Manager and Senior Management consisting of the Pathology Manager and a Senior Biomedical Scientist to give an insight into the consolidation process, maintaining the service during the consolidation and lessons learnt following the consolidation. As part of this, the role of the microbiology laboratory was discussed including staff requirements, financial savings and acquisition of new equipment.

Data was collected using the LIMS (Telepath). TATs were calculated as the difference between time from specimen receipt in laboratory to reporting of result for five urgent/time-sensitive specimen types. The time from specimen collection to receipt in laboratory was also calculated. The five specimen types were blood cultures, CSF specimens, genital specimens, and antibiotic assays (gentamicin and vancomycin). Pre-consolidation, data was collected for a period of three months, 1^st January 2018 to 31^st March 2018, inclusive and compared to data collected post- consolidation for the same length of time (1^st January 2019 to 31^st March 2019). Selecting these months avoided the seasonal variation over the winter period, staff annual holidays and the initial months following consolidation which could all affect the type and volume of samples received and as a result the TATs. Data were entered into spreadsheet software (Microsoft Excel) and analysed using standard descriptive methods.

Results

Service users feel centralising microbiology services would have a negative impact:

Only 16 responses were obtained from service users. Respondents included: BW ward staff (such as healthcare assistants, a junior sister, and staff nurses), community midwives, Milk Bank Practitioner, digital strategy midwife and antenatal screening coordinator. Of the service users that responded, 38% were sending >20 samples to microbiology weekly so were regular users of the service and 75% of respondents were overall happy with the service the microbiology department were providing at BW prior to consolidation. Although a majority result, it showed there was room for improvement. Suggestions on how to improve the service included only providing printed reports for significant or abnormal results, integration into BadgerNet (the paperless record of care for all babies within neonatal services) and ICE training. This suggestion was reiterated by the fact that 36% of respondents thought implementing ICE would have a positive impact. Results show that 87% of respondents felt centralising microbiology services at BC and having no microbiology service at BW would have a negative impact, with 13% feeling there would be no impact. As a result of centralising microbiology services, all specimens would have to be transported to BC at set times during the working day and 73% found this would have a negative impact. However, 67% of respondents felt an extended working day and an extended working week would have a positive impact.

Pathology staff feels the laboratory environment had not been enhanced post-consolidation:

The pre-consolidation pathology staff questionnaire was circulated to all 22 members of both microbiology departments and covered all grades of staff. From the total 22, 6 staff members were located at BW prior to consolidation of which the response rate was 100%. The remaining 16 were located at BC and the response rate was 69%, making the total response rate pre-consolidation 77%. A member of staff at BC was due to retire prior to the process and so their response was excluded from this data set. The remaining staff went through a competitive selection process. During the consolidation, 3 members of staff were at risk of redundancies, 2 of whom left and 1 was displaced into a new role elsewhere in the Trust. The consolidation contributed to 2 out of 4 members of staff’s decision to resign. As a result the microbiology workforce decreased by 36%. Interestingly, staff felt less secure in their positions post-consolidation, as shown in Figure 1. The post-consolidation pathology staff questionnaire was given to the 13 staff members who made up the consolidated microbiology laboratory at BWC six months post-consolidation. There was a response rate of 46%.

 

 

 

Figure 1. Higher percentages of staff felt insecure in their position post-consolidation than pre-consolidation. Staff were asked how strongly they agreed or disagreed regarding how secure they felt in their positions both pre and post-consolidation.

Turnaround times were not compromised following consolidation:

The results for mean turnaround times for the five specimen types are summarised in Table 2. According to the pre-consolidation user handbook, 100% blood cultures should be reported after 3 days which was being met. Although the mean TAT increased post-consolidation from 2.61 days to 5.2 days, over 90% blood cultures were reported within 6 days which met the new recommended TAT. The mean TATs for the remaining chosen specimen types improved [8]. This has been well illustrated with CSF specimens (Tables 3 and 4). Despite TATs being sustained or improved post-consolidation, 66% of staff still felt the consolidation did not have a positive impact on the service or improve the quality of patient care (Figure 2). Furthermore, 33% disagreed the consolidation had been a success (Figure 3).

Table 2. Mean and standard deviation (SD) of TATs over 3 months pre and post-consolidation.

	Mean TAT pre-consolidation (days)	SD	Volume of specimens received	Mean TAT post-consolidation (days)	SD	Volume of specimens received
Blood cultures	2.61	6.94	889	5.2	1.41	949
CSFs	3.10	0.94	28	2.08	0.24	48
Genitals	2.33	0.79	1,909	2.04	0.32	1,765
Gentamicin	0.85	1.04	360	0.00	1.00	416
Vancomycin	0.78	1.04	79	0.11	0.70	143

 

 

 

Table 3. Percentage of CSF results available within the recommended turnaround times pre-consolidation over a period of 3 months. Pre-consolidation,100% of CSF specimens were reported within 5 days, as recommended by the user handbook, however less than the recommended 90% were being reported within 3 days.

 

Month	Volume of samples received	% reported within 3 days	% reported within 5 days
Jan 2018	11	81%	100%
Feb 2018	9	78%	100%
March 2018	8	75%	100%
Total	28

 

 

Table 4. Percentage of CSF results available within the recommended turnaround times post-consolidation over a period of 3 months. Post- consolidation,

100% of CSF specimens were reported within 5 days, as recommended by the user handbook. 100% were also reported within 3 days, an improvement from pre-consolidation data, despite the increase in the number of specimens.

 

Month	Volume of samples received	% reported within 3 days	% reported within 5 days
Jan 2019	15	100%	100%
Feb 2019	21	100%	100%
March 2019	12	100%	100%
Total	48

Figure 2. Staff viewpoints on the impact on the Microbiology service and the quality of patient care pre and post-consolidation. The data shows staff became increasingly negative regarding the consolidation and believed there had not been a positive impact on the service and quality of patient care had not been improved six months post-consolidation.

 

 

 

 

 

 

 

Figure 3. Majority of pathology staff neither agree nor disagree that the consolidation has been a success. Results obtained from questionnaires distributed to staff six months post-consolidation show higher percentage of staff disagree that the consolidation was a success.

 

Discussion

Birmingham Children’s Hospital site offered the best clinical service at lowest cost:

It was agreed to consolidate services at the BC site due to the clinical need; it potentially offered the best clinical service at the lowest cost [8]. There were various factors that were considered. The size and condition of the BW laboratory would not have met the requirement of The United Kingdom Accreditation Service (UKAS) without substantial investment, whereas the BC laboratory had sufficient space to accommodate BW work, equipment and staff with only minor reconfiguring and investment required [10]. Since the BC laboratory provided a greater test repertoire prior to the consolidation, the BC laboratory had the capacity to absorb BW work. It was identified that there would be a need for some additional test verifications and equipment validation regardless of the chosen site, however consolidation to a single site would eliminate duplication [5] and ensure that all tests offered to patients at BC and BW were verified to the same local standard. Consolidating at BW would mean the laboratory is remote from the site where more patients would benefit from clinical microbiology input [2]. Although this could be mitigated by good electronic and person-to-person links, there was a greater benefit to consolidating at BC site with the only downside being that the laboratory is remote from the neonatal intensive care unit at BW [4]. However, microbiology consultants and infection prevention control staff based at BC were already attending BW regularly which would continue post-consolidation. Both microbiology consultants were involved in the decision to consolidate services and so together would ensure that consolidation on to a single site would result in a more efficient clinical liaison, especially since greater clinical microbiology input is needed for antibiotic stewardship and infection prevention and control [1, 2]. For this reason, the microbiology consultants were not invited to participate in questionnaires or interviews. Since finance was a major drive for the consolidation, it was deemed too much of an expensive option to consolidate at BW. This was due to more staff being affected by the move and so payments to support the transition of staff (travel and pay protection) would potentially be higher, as well as the extra capital required to improve the condition and capacity of the BW laboratory. The cost associated with transport of specimens would be the same for BW and BC.

Pathology staff did not feel well supported post-consolidation:

Streamlining the organisational structure of the laboratory in terms of personnel was one way in which cost savings was made. Whilst early retirements and resignations suited the proposed consolidation [13], there was a significant loss of technical and senior experience at a time of major change and reorganisation. Other laboratories have also found that it is not preferable to reduce the staff workforce until later in the consolidation [10, 13, 15]. The proposed staffing structure consisted of the following bands: 8(1), 7 (3), 6 (4), 5 (3), 4 (1), 3 (6), when in reality, the allocation of grades that remained were bands 8 (1), 7 (2), 6 (4), 5 (2), 4 (1), 3 (4). The outcome of this was a team of staff that felt their workload had not been reasonable following consolidation which again is similar to the sentiment felt by staff in the Cincinnati consolidation in 2002 [10]. Results also showed that 83% of staff felt unsupported post-consolidation and that the laboratory environment had not been enhanced. Comments from staff included: “too little staff for first 6 months post merger causing more stress for all levels”, “we were thrown in the deep end and expected to swim” and “the first few weeks were dreadful”. Research from Gray echoes this viewpoint [13]. Although there had been recruitment of capable individuals since, a Band 6 and two Band 3s, the loss of experience did have a negative impact on laboratory efficiency initially [5, 10]. Following interviews with senior management, there was improved performance six months on, but it was likely that another six months would be needed to reap the benefits of consolidation. Ansara recommends good results are experienced a year into the consolidation [10]. Consolidation onto a single site would increase training opportunities associated with a larger laboratory with a wider test repertoire [13]. From the pre-consolidation questionnaire it can be seen that only 31% of laboratory staff were excited for new opportunities that would result from the transition suggesting staff might not have seen or be made aware of these opportunities at the time. This could be a result of the initial resistance to change which is inevitable. However, six months post-consolidation, staff felt increasingly insecure in their positions (Figure 1). This indicates more time may be needed for staff to feel more positive about the opportunities [5].

Results from questionnaires and interviews carried out for this study are similar to those seen in studies for other Trust mergers. They show that changes have had a major impact on staff involved. For some, this included a significant re-location of workplace, different working hours, a different role and increased workload [10]. Potential financial losses to staff, as a result of these changes, were supposed to be pay protected, however six months on, there was still no clear clarification as to if BW staff were entitled to travel and pay protection and if so, when payments would be received. Natural wastage has resulted in only three staff members from BW still being employed. The fear and uncertainty around change should not be underestimated and can be complicated by physical factors such as travelling time to work to emotional factors associated with transitioning from one workplace to another and potential dilution of strong working relationships as a result of department expansion [10].

Staneck lists some key elements to successful management of change as being communication, cross training and collaboration [5, 16, 17] all of which was apparent from responses received in the pathology staff questionnaires. For example, prior to consolidation, only 31% of staff agreed that microbiology departments on both sites had collaborated well to make the transition successful and 31% believed in management’s ability to make this transition successful. Therefore it can be seen that, management should remain unified in their mission of consolidation and not get territorial of their own departments. The transfer of skills should be encouraged in advance of the consolidation [10] as 67% of staff felt they had not had the necessary training for them to successfully adapt to changes following consolidation.

The main conclusion that emerged from feedback from service users was the importance of early communication with service users in order to answer their queries and increase their understanding of the process and how it would impact them. This concurs with the experience had by Health Alliance Laboratory Services in 2002 [10].

Information technology (IT) was another significant challenge that had still not been overcome six months post-consolidation. The IT infrastructure had been highlighted at the time of the proposed consolidation and continued to be an issue. Failure to implement appropriate LIMS and interfacing equipment had a huge negative impact on efficiency. All staff provided feedback that this had been promised and was not delivered. Complaints were also received from service users regarding the accessibility of results. Many of the issues experienced following consolidation were directly due to the IT system, or lack of [10]. However the department had made further progress in going paperless with the introduction

of ICE at BW.
 

Although a difficult adjustment for staff overall studies, along with this one, suggest the benefits of consolidation outweigh any drawbacks [5, 8].

Patients did not suffer as a result of consolidation:

Five urgent/time-sensitive specimen types were chosen to audit. The number of specimens received for each specimen type was recorded to gauge the workload along with data to evaluate the TATs. TATs were used as a quality indicator to evaluate microbiology laboratory performance and consequential impact on patient care [15]. A decreased TAT means less unnecessary or additional tests. It also reduces unnecessary empirical treatment that may be administered whilst waiting for laboratory results. From a patient’s perspective, improved TATs means reduced waiting time and immediate treatment if necessary, all which leads to a better patient care experience [15].

The department receives a wide array of genital specimens, the majority being high vaginal swabs. Some urogenital pathogens, e.g. Neisseria gonorrhoea and Trichomonas vaginalis rapidly lose viability on swabs [8, 13] as biological material on swabs dries out rapidly. Therefore these specimens must be transported to the laboratory as soon as possible to achieve the optimum diagnostic yield [2, 4]. Prompt screening and reporting of sexually transmitted infections is essential as many cases are asymptomatic which can contribute to the spread of infections as well as cause complications if left untreated [18]. Prior to consolidation the average time between collection of a genital specimen to receipt in the laboratory, over the set period of three months (1^st January 2018 to 31^st March 2018 inclusive), was 0.54 days. The concern after consolidation was that this time would increase leading to substantial delays in receiving and processing specimens [2, 8] and therefore underreporting of pathogens [13]. The average times between collection of specimen and receipt of the different specimen types pre and post-consolidationis illustrated in Figure 4. The average time post-consolidation was found to be 0.52 days. This improvement could be attributed by the extended working day and week that was implemented post-consolidation [5, 19]. Transport delays have been experienced resulting in receiving specimens from BW too late in the day [8]. Consequently, this was reviewed and an extra transport time was added in the afternoon to deal with the surge of specimens from community midwives. Despite this, staff has reported that transport times are variable and there is “still inconsistency with taxis meaning samples can take a long time to arrive”. This could be a reason why pathology staff don’t believe the consolidation to have been a success (Figure 3).TATs were being met successfully prior to the consolidation, the results show that they continue to be met post-consolidation which is promising [12]. To increase isolation rates of important urogenital pathogens and further improve TATs, there are ongoing discussions taking place to introduce molecular platforms for such specimens [3, 10, 19]. Molecular detection methods allow for a more sensitive and specific diagnosis of fastidious organisms [1] and are less time consuming than culture methods. More importantly, they do not depend on the viability of organisms [8] which can be affected by a long transport time. A further recommendation to increase isolation rates and reduce the impact of transport time would be to use a Trichomonas vaginalis media. Feinberg and Whittington found that the use of a specific medium increased yield rates [20]. Another way in which patient care could potentially be compromised as a result of specimens being transported from BW to BC, is specimens getting lost in transit [13].

Figure 4. Average times taken from collection of specimen to receipt of specimen pre and post- consolidation show improvement over a period of 3 months. Improvements were seen in all specimen types except blood cultures (BCs). Vancomycin assays showed a 47% decrease in the time taken from collection of specimen to receipt of specimen in the laboratory.

As with any consolidation, decisions regarding which equipment to retain and discard are made based on cost effectiveness, ease of use and efficiency. The Vitek 2 from BW was kept along with the matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), originally located at BC, both of which are commonly used to perform organism identification and antibiotic susceptibility testing [16].

The Vitek 2 gives rapid (4 to 15 hours) and accurate results for microbial identification and antimicrobial susceptibility testing for a range of organisms [21, 22]. Although identification with the MALDI-TOF MS still requires a culture, direct identification of organisms from the sample itself can be performed usually on positive blood cultures and with sample extraction taking only 6 minutes [23], the MALDI-TOF MS is slowly becoming the gold standard for identification [24]. Data from Staneck shows the positive impact on outcome due to rapid reporting of identification and susceptibility testing i.e. same day as isolation. There is lower percentage mortality due to infection as well as a lower overall cost if reported on the same day compared to next day [17]. Therefore it can be seen that, automation has enhanced the laboratory’s ability to identify organisms [1, 5, 8, 15].

Continuous-monitoring blood culture instruments, such as the BacT/Alert at BW prior to consolidation, have shortened the time to detection of positive blood cultures when compared with earlier methods [16, 17]. However the time benefit is debatable due to most laboratories, including microbiology at BWC, not loading blood culture bottles or processing positives during the night. This discontinuity in workflow can cause delays in starting incubation and also processing positive blood cultures. Again, this has been improved by the extending working day and week post-consolidation [8] but is not reflected by the results from this study. The average time taken from collection of a blood culture to receipt in laboratory post-consolidation was 0.51 days. This is 1.2 hours greater than pre-consolidation (Figure 4). Both pre and post-consolidation times do not meet the recommendation made by Public Health England (PHE) which states that “inoculated bottles should be loaded to continuous monitoring blood culture systems as soon as possible and within a maximum of 4 hours” [25]. This emphasises the importance and urgency of blood cultures. Clearly, current practice was not meeting the needs of optimum sepsis management. Senior management therefore found the consolidation a good time to invest in new and multiple BD BACTEC FX systems for blood cultures [13] and improve on current practice, as staffing the department 24/7 was not realistic. Appropriate placement of these instruments would allow ward staff access [8] to load inoculated bottles as soon as possible after collection and within the recommended 4 hours, in particular during out of hours. Minimising the time between collection and receipt and receipt and reporting increases the clinical use of blood culture results, therefore improving patient care and outcomes [8, 15]. Another reason for a new blood culture system was because the previous system at BW did not have enough capacity to deal with the amount of blood cultures that would be received post-consolidation and the system at BC was outdated. However, six months later, the new blood culture system had still not been procured and as a result, both BW and BC old blood culture systems were being used. Overall, TATs for blood culture specimens were being met so patient care was not impacted.

Assays of routinely used antibiotics (gentamicin and vancomycin) were always performed at BC. Post-consolidation, the average time between collection and receipt in the laboratory had reduced. However there is room for improvement when it comes to TATs by processing these specimens on the late shift, as the raw data suggests any received 16:30 onwards are not processed until the following morning. Having a cut off of 19:30 instead will not only improve TATs but also improve patient care.

Finally, CSF specimens are analysed to establish a diagnosis of meningitis. Bacterial meningitis is a medical emergency [26] hence the need for the specimen to reach the laboratory with minimal delay. Although antimicrobial therapy may be started empirically, further patient management decisions are made based on the immediate examination of the CSF specimen i.e. cell count and Gram stain [26]. This result is typically telephoned to the requesting clinician within two hours of receiving the specimen. This was not audited on this occasion. However, the TAT shows that 100% of specimens were reported within the recommended time of three days in January, February and March 2019, which is an improvement from the pre-consolidation data (Tables 3 and 4). This could be attributed to faster transit times (Figure 4).

 

Strengths and Weaknesses:

The impact of consolidation has been assessed narrowly using TATs and TAT related data. The recommended TATs pre and post-consolidation were not comparable making analysis difficult and the data potentially insubstantial. Future studies should involve investigating the quality and efficiency of health care in the broader sense by auditing patient outcomes in terms of length of hospital stays, readmission rates and mortality rates. It would also be useful to use a longer time period to evaluate post-consolidation to see whether things improved as systems settled down.

The impact of transport on the specimen diagnostic yield [2] has also not been measured. This would be valuable in order to determine if there is opportunity to optimise diagnostic yield and further improve patient care.

The number of responses received from service users was a tiny proportion of people who were invited to participate and no responses were received from medical staff. Having a low response rate could reduce the reliability and validity of results.

A qualitative approach to this study was appropriate to evaluate the impact on pathology staff as it allowed for open-ended inquiry. Although using questionnaires was cost efficient, it was a time-consuming process and did not culminate in an objectively verifiable result.

Conclusion

It has taken a great deal of planning and work to unite BW and BC to create a single NHS Foundation Trust. The hospitals’ names and locations remained the same, but the new united microbiology department provides a more seamless service for the patients. Centralising services at BC has ensured a strong specialist expertise in one location [10]. It has led to a financial saving of greater than 10%, improved standardisation of tests and procedures, expanded the test repertoire [10] and allowed for new roles and opportunities for staff, without compromising the quality of the service [5, 13, 27]. Quality is successfully being maintained. This is evident from the UKAS inspection which the department passed with few non-conformances. However, it has shown the necessity for effective communication [10], transparency and support as well as the need for implementing an IT infrastructure that is fit for purpose prior to consolidation instead of rushing consolidation [13].

Although the studies described were limited in scope, microbiology consolidations, including this one, have proved successful and cost effective [5, 7, 8, 9, 10]. More microbiology consolidations are imminent [4] and so it is essential that lessons are learnt from those who have undergone them.

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Appendix

Inclusion of this appendix has been approved by the Research Project module convenor.

 

Appendix 1a: Pre-consolidation service user questionnaire

1. What type of service user are you?

1. Trust/Clinical
2. Trust/Non Clinical
3. GP surgery/ Medical Centre
4. Other

For each of the questions below, please circle the response that best characterises how you feel about the statement, where 1= Strongly Disagree, 2= Disagree, 3= Neither Agree Nor Disagree, 4= Agree, and 5= Strongly Agree.

	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree
I am able to access the Pathology User Guide on the Trust website	1	2	3	4	5
It is easy to use paper pathology request forms	1	2	3	4	5
Local systems to collect and transport specimens work well	1	2	3	4	5
I can trust the laboratory to provide results/reports when I need them	1	2	3	4	5
The laboratory report is clear and understandable	1	2	3	4	5
I am confident that urgent/unexpected results will be promptly communicated to me or my cover	1	2	3	4	5
I am satisfied with the quality of professional advice that I receive from the laboratory	1	2	3	4	5
Professional advice is readily available from the laboratory when needed	1	2	3	4	5
Point of care testing is well supported by the laboratory	1	2	3	4	5
The level of out of hours service meets my needs	1	2	3	4	5
There is a difference between laboratory services at different times of the day/week	1	2	3	4	5
I would recommend this laboratory service to a colleague	1	2	3	4	5

14. Do you anticipate any development or changes in clinical practice which will affect your demands on the laboratory servi ces in the next 12 months? If so, please provide details:

15. Do you have any suggestions on how the service could be improved?

Following consolidation of services, the following developments may take place. Please rate the impact on your service by circling either positive, negative or no impact.

Services centralised at BCH (No microbiology service at BWH)	Positive	Negative	No Impact
Extended laboratory working hours 8am-8pm (as opposed to 9am-5.30pm)	Positive	Negative	No Impact
7 day working week (including Microbiology laboratory service 9-5.30pm Saturday, Sunday and Bank Holiday)	Positive	Negative	No Impact
Electronic requesting and viewing of results via ICE	Positive	Negative	No Impact
Transport of all specimens to BCH at set times during the day	Positive	Negative	No Impact

 

 

	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree
The reasons for consolidation of microbiology services have been communicated clearly and effective.	1	2	3	4	5
I know where to find additional information about the consolidation of services.	1	2	3	4	5
During this transition, my workload has been reasonable for my role.	1	2	3	4	5
I have been included in decisions that affect my job role and work.	1	2	3	4	5
I feel secure in my current position.	1	2	3	4	5
I believe in management’s ability to make this transition successful.	1	2	3	4	5
I believe management will provide necessary training for me to successfully adapt to any changes in the transition.	1	2	3	4	5
Microbiology Departments on both sites have collaborated well to make the transition successful.	1	2	3	4	5
I believe the merger will have a positive impact on the service and improve the quality of patient care.	1	2	3	4	5
I am excited for the new opportunities that will result from this transition.	1	2	3	4	5

Appendix 1b: Pre-consolidation pathology staff questionnaire

 

 

	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree
Post- consolidation, my workload has been reasonable.	1	2	3	4	5	Not Applicable
I have had necessary training for me to successfully adapt to changes following consolidation.	1	2	3	4	5	Not Applicable
I have been given an opportunity to give feedback post consolidation.	1	2	3	4	5	Not Applicable
I feel well supported post-consolidation.	1	2	3	4	5	Not Applicable
The laboratory environment has been enhanced.	1	2	3	4	5	Not Applicable
I feel secure in my current position.	1	2	3	4	5	Not Applicable
I believe that consolidation has had a positive impact on the service and has improved the quality of patient care.	1	2	3	4	5	Not Applicable
I deem the consolidation to be a success.	1	2	3	4	5	Not Applicable

Appendix 1c: Post-consolidation pathology staff questionnaire