Microbiology ABM Service Review 2012

32 Pages·2013·0.67 MB·English

Microbiology ABM
Report of Project Board
Public Health Wales Microbiology ABM
Service Review

Author: Dr. Nidhika Berry& Ian Thomas
Sponsored by: Dr. Mark Hastings, Director, Microbiology Division, Public
Health Wales

Date: 17th June 2012 Version: 1

Purpose and Summary of Document:
Report of Project Board - Public Health Wales Microbiology ABM
Service Review

Name of director: Dr. Nidhika Berry – Microbiology ABM

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Situation
In April 2011, Public Health Wales Microbiology ABM decided at its Annual
Management Review to undertake a review of Microbiology services
provided by PHW Microbiology ABM to the ABM Health Board. It asked a
project team to review current service provision with a view to future
sustainability and effectiveness. This report provides the strategic and
operational background, details of the review process, and options for
change, assessment criteria and recommendation for a new service
model.
Background
The “National Pathology Framework” (NPF) for Wales provides standards
for the planning and delivery of pathology services in Wales. It is
supported by the “Future Delivery of Pathology Services in Wales”, which
sets out a number of recommendations that pathology services need to
consider in delivering services into the future. PHW has developed
service strategies for 2010 – 2015, which have a direct bearing on
microbiology services.

In addition, PHW has identified a number of acute, specific operational
issues affecting various aspects of the services provided in ABM

 Ongoing challenges in meeting increasing service demand
(diagnostic/clinical) within current resources.

 Imminent pressures on retaining capacity to deliver emergency
services (on call).

 Increasing difficulty in maintaining service quality with little capacity
or scope for service improvement.

 Increasing demands in meeting training requirements including
statutory and mandatory training and staff development needs.

 Inability to respond to need for service development in meeting
clinical service requirements for improved patient management
(e.g. 7 day working, local delivery of molecular technologies).

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 Limited capacity to respond to outbreaks and other infection
emergencies.

 Limited capacity and capability to deliver specialist Public Health
Services.

 Difficulty in meeting current savings targets, with little scope within
current structures, for meeting future savings necessary to address
the ongoing financial pressures placed on NHS Wales.

It was therefore agreed to undertake a review of current microbiology
services across ABMUHB and to develop a strategic and operational plan
that addresses the current and predicted workforce challenges, service
demands and financial pressures, whilst ensuring continued delivery of
effective and sustainable microbiology services for the population of
ABMUHB , and to answer the key strategic question -What is the most
effective and sustainable model for the delivery of microbiology services
within ABMUHB in support of frontline patient care within the available
resources?

A Project Board was established, consisting of senior medical, scientific
and management staff from within Public Health Wales ABM Microbiology
services, Public Health Wales Microbiology Division and ABMU Pathology
staff together with PHW human resources and PHW ABM Microbiology
staff representatives. Two work streams were set up to review the
existing services and to identify the key issues for assessment of any
service changes, together with developing the possible future service
delivery option with reference to a comprehensive standard for
“timeliness” of testing the full range of specimen types processed locally,
consistent with the standards proposed within the “Future Delivery of
Pathology Services in Wales” guidance.
Each laboratory was visited by members of the Project Team to engage
with staff.

Assessment

Work stream 1:-_ reviewed the current position within the 2 laboratories
looking at workload, skill mix etc. Their report is included in Appendix 1.
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Work stream 2:- A number of potential service models were considered,
Management options: - (already under single management)
 Public Health Wales NHS Trust
 ABMU Health Board
 Other organisation e.g. private company

Agreed core services at acute sites
 Specimen reception
 Consultant medical microbiologist (on-site as appropriate according
to clinical services provided)

Service model options (discussed at Work stream 2 meetings)
Existing relationships e.g. with ABMU HB Pathology Service and Swansea
University would need to be considered.
 Single site laboratory

1. New build or refurbishment of an existing building near M4
west (this would provide a Mid & West Wales option for a
future service)
2. Morriston Hospital (MH) site (currently there is no space to
relocate microbiology to the Pathology Block in Morriston)
3. Neath/Port Talbot Hospital (currently there is a small
laboratory at NPTH and there is no space to relocate
microbiology to NPTH)
4. Princess of Wales Hospital (POWH) site (space, moving
automated equipment, molecular diagnostics and other
enablers would need to be considered). Existing relationships
with University and reference units need special consideration.
Singleton Hospital (SH) site (space would need to be
considered with ABM Pathology services). Existing
relationships with University and 2 UK reference units would
remain as such.
 Two site laboratory

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1. Single site bacteriology service (SH) with virology relocated to
POWH site. The resources required for moving automated
equipment and molecular diagnostics should be considered.
2. Single site microbiology service (SH) with Cryptosporidium
and Toxoplasma Reference Units relocated to POWH site. The
resources required for moving specialised toxoplasma facilities
and molecular diagnostics should be considered.
3. Move bacteriology work flow from Neath Port Talbot Hospital
and NPT Locality from SH to POWH. The required duplication
of equipment should be considered and the rationale for this
option should be discussed further.
4. “Sample-type” option i.e. all of 1 type of sample would be
processed at 1 site e.g. all urines at SH, mycology at POWH.
The required duplication of equipment should be considered.
5. Establish Infection Prevention and Control Laboratory in
POWH (processing of screening and environmental specimens
etc) and all other microbiology samples processed in SH. The
required duplication of equipment should be considered.
6. Blood sciences option. Serology/virology specimen processing
would be integrated with AMBU HB blood sciences multi-
disciplinary laboratory.

Agreed Final Options :-

Option 1: Consolidation of workload onto one single site laboratory
situated near the M4, and preferably in association with
other pathology disciplines. There would need to be
special consideration of the requirements of Swansea
University and the reference units.

Option 2: Establish an Infection Prevention and Control laboratory
in POWH (processing of screening and environmental
specimens etc.) and all other microbiology samples
processed in Singleton Hospital.
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Service Delivery Models

It was agreed that any service delivery model would have to provide the
following minimum service on each hospital site:

 On-site specimen reception

 On-site Consultant Microbiologist (as appropriate for clinical services
provided).

In addition, any service change would need to be underpinned by
effective inter-site transport and robust IT.Each option would need to
deliver outputs in a number of areas i.e.

Quality
 Accreditation (CPA)
 Accessibility of service
 Timeliness of results and advice (incorporating out of hours
arrangement and weekend working)
 Governance arrangements/safety of service

Efficiency

 Costings and economies of scale
 Critical mass/potential for automation
 Transport arrangements

Workforce

 Sustainability and succession planning
 Training and development
 Service re-design implementation plan and costs

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R & D/Horizon scanning/Service Development

Timeliness
(The maximum time between specimen collection and initial
processing/reporting, based on clinical requirements and specimen
stability):

 Urgent (up to 4 hours) – CSFs, joint fluids, other urgent specimens
agreed between senior medical staff

 Clinically imperative (up to 12 hours) – blood cultures, pus/tissue,
PD/Ascitic fluids, SCBU septic screens

 Routine (up to 24 hours) – swabs, sputum, C. difficile toxin, MRSA
screens

 Low priority (48 hours) – Faeces bacteriology, virology, urines,
routine SCBU screens

NB. It is important to emphasise that these represent the
maximum acceptable time, and in practice, most samples would
be processed as soon as practicable.

In order to meet the above requirements it is necessary to offer a
7 day a week service based on an extended working day, with a
commensurate reduction in the number/range of specimens examined by
on call staff.

Recommendations

1. Microbiology services provided by and hosted within ABMUHB shall
be consolidated onto a single site laboratory where possible and
remain within a single, integrated management structure.
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2. A service delivery plan shall be developed based on the principles of
the “Future Delivery of Pathology Services in Wales”, and operating
within the allocated budget.

The preferred option is a consolidated service (Option 1) with the
presence on hospital sites of an On-site Consultant Microbiologist as
appropriate for the clinical services provided) and an on-site
specimen reception.
3. The Review Group has given consideration to the location of the
consolidated services; it was agreed that, taking into account
current ABM UHB acute services, PHW Microbiology ABM capital
requirements, transport and timeliness issues and staff impact, a
site at Morriston Hospital or close to the M4 west motorway was the
most suitable option.

4. Maintenance on each hospital site of sufficient resource to ensure
appropriate clinical support, and sample reception.

5. An implementation plan supported by an implementation team will
need to be developed, setting out timescales and detailing the
mechanism of subsequently introducing changes in service delivery.
The plan will also need to include detail on how staff and service
users will be supported through the change process.

6. A Risk Register needs to be developed for all contingencies,
including consolidation of testing.

The implementation of the recommendations will need to be undertaken
as a formal organisational change process and will require a co-ordinated
management/staff partnership approach with full consultation of staff and
significant support from Finance, Human Resources, Business and
facilities management within both organisations.

Appendix I

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Workstream 1. Final Report
Remit.
The remit of Workstream 1 is to gather and verify the data available for
the microbiology service:
 To inform on the current service profile, the activity profile
 Staffing data including establishment numbers and skill mix
 Facilities and equipment including IT and current transport
 Current service delivery area
 Current service costs
The primary purpose of this data is to clearly understand, model and
properly cost service redesign.
Current Service Profile.
Microbiology Services are currently delivered from two sites within Public
Health Wales ABM Microbiology Laboratories (located at Swansea and
Princess of Wales).
The cumulative workload for both sites eqeuates to 34.8% of workload
for the Public Health Wales Microbiology network.
Appendix 1 The individual breakdown of total number of specimens for
each test.
Appendix 2 illustrates the total percentage workload split between
individual acute inpatient sites and outpatient/LHB
Public Health Wales ABM Microbiology, Swansea, consists of Bacteriology
and Virology and two reference units, the Cryptosporidium reference Unit
and the Toxoplasma Reference Unit. Public Health Wales ABM
Microbiology Princess of Wales site performs Bacteriology investigations.
Bacteriology

Both bacteriology departments provide a full clinical diagnostic
bacteriology and infection service to the ABM University Health Board,
which incorporates Singleton, Morriston, and Neath/Port Talbot Hospitals
in the west and the Princess of Wales hospital in the east, as well as a
full microbiology service from both sites to all local general practitioner
practices (99).

These arrangements are facilitated by a Service Level Agreement between
the ABMU Health Board and Public Health Wales and includes quality of
services, volumes and turnaround times etc.

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Specimens examined include urines for culture and pregnancy testing,
CSF, tissues, bone and joint, sterile fluid, pus/wound swabs, respiratory
samples, genital, enteric and blood cultures. Antibiotic profiles are
provided, together with clinical interpretation for organisms considered to
be clinically significant.

Within the Bacteriology department, a range of mycology services are
provided which include the dermatophytes, and respiratory fungi or
identification of fungi from other sites. Molecular tests are performed off-
site and forwarded to the relevant CPA accredited laboratories e.g.
N.meningitidis, S.pneumoniae, and Mycobacterium tuberculosis and
referral to reference units.

Specialist Virology Unit

The specialist virology unit offers a comprehensive service to ABM UHB
and Hywel Dda and Cwm Taf Health Boards. The department handles
ante-natal serology testing on an automated platform interfaced to the
pathology LIMS. A rapid hepatitis, HIV serology service is provided by an
interfaced random access analyser.

Specimens from any outbreaks or incidents which need molecular typing
are referred to HPA Colindale (VRD).

 A rapid respiratory virus service is provided to all parts of ABMU
(which has been standardised across Wales). Conventional serology
tests such as CFTs are carried out as well as IgM assays for links
with other accredited laboratories. The department provides advice
on clinical interpretation of results and patient management.
 Chlamydia diagnosis by NAAT has now been provided across ABM
UHB (including to GPs). Gonococcal NAATs provided since
September 2011 to sexual health services at no extra cost.
 Virus isolation, which was a lengthy process and delayed results,
has now been replaced by PCR, including HSV1&2, VZV and
adenovirus. This is provided to all GPs and clinical areas within the
hospital for genital, skin and eye swabs.
 Planned provision of syphilis PCR in 2012 to enhance early diagnosis
of syphilis.

Cryptosporidium Reference Unit

The Cryptosporidium Reference Unit provides a comprehensive range of
specialist and reference services to Public Health Wales, NHS and HPA
laboratories throughout England and Wales (and Scotland until 01/04/12)
and private hospital laboratories within the UK and elsewhere in the EU.
These services include traditional parasitological examinations and
molecular assays for the detection, confirmation and characterisation of
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